Ace844 Posted July 15, 2006 Author Posted July 15, 2006 Hello Everyone, Great responses and effort as well as clinical thinking thus far. Now lets move on. After performing all of the necessary H&P-P/E as noted previously in the thread you extricate your patient to the ambulance, and since we have decided to treat this patient ALS, we are going to do so. We have also decided to allow a basic to assist us in the patients care as needed. We then begin transport to a hospital 20+ mins away. Additionally we perform the following: Tests and LABS as requested here are the results: NA+ : 120 K+: 3.4 Cl: 90 Glu: 78 BUN: 12 CRE: 1.2 WBC: 10 RBC: 14 PLT: 380 HGB: 12 HCT: 38,000 B-HCG: - Blood Cultures: Pending, expected results in 24-48 hrs…. No tenderness, or rigid nodes palpable, no lumps present on P/E That aside, all of the CT’s were – for abnormal anatomy of findings. She hasn’t urinated in 16+ hrs, she has had no PO intake in that time as well., her temp is 100.8 F For those just joining us here’s a recap of the pt. You are working in a combo half urban half suburban dual response EMS system ( which is quite progressive and gives you all the toys you wish you could have). You have just sat down with your coworkers to enjoy a nice mid-morning "viewing" of Lucky # Sleven. you are enjoying your post sit down breakfast high with a coffee when shortly after the first 5 minutes of the movie you get toned and dispatched for a call..Theres a surprise..... :?: :!: :?: [marq=left:62c8fd1b3b]"This is ******* FD brocasting a still alarm for E-1, A-52, P-26, to 5222 River ST on the 2nd for a 22yo F not feeling well."[/marq:62c8fd1b3b] You arrive in a nice suburban neighborhood to at the same time as the PD, and fire. Mom meets you just inside the door and says My daughter is really sick. She's weak and dizzy all over, shes in her room and has been getting worse over the last 36 hrs...we want her to go to ______ General You bring all of your equipment to the second floor where you find your patient lying supine on her bed. Her mom tells your partner the following info.; your pt has a hx of ectopic pregnancy (5 mos ago), HPV, migraines, and she smokes. She takes birth control pills and imitrex for the migraines, Tylenol and Alieve. The Pt and has no known allergies. Socal Hx: Has been having sex with BF regularly for last 4 mos, she started the birth control regimen after the ectopic in the hosp. She’s not on any anti-virals and she denies illicit use or tox exposure, and mom relates the same family Hx of colon CA and breast CA, and HTN, Heart Disease Upon patient contact you find an obese 22yo patient with pale, hot dry skin, writing on the bed holding her head, and her eyes are tightly shut. You initially gather the following information. She started feeling weak and dizzy about a day and a half ago. This was followed by consistent migraines which she has been unable to relieve with tylenol, alieve and imitrex. Last night she states she started vomiting ( has vomited 4x total large amounts)and noticed that she was having trouble seeing, as well as occasionally loud pounding in her ears. When she tries to stand she states she feels very dizzy. She was walking with her boyfriend down the road smoking; she felt weak, and dizzy then got this loud rhythmic pounding in her ears. She had to sit down for 10 mins. Then, was able to continue. The sx’s resolved and later came back as mentioned in the first post while watching TV and drinking coffee and smoking cigarettes. The sx’s resolved and later came back as mentioned in the first post while watching TV and drinking coffee and smoking cigarettes. No recent trauma and she is orthostatic. Pt states the Sx’s worsening with Position, and exertion. Discomfort initially was a 4, then the symptoms were transient through the first night. On day 2 they became constant and worsening. Now the discomfort is a 10. When she tries to stand or sit up ‘things just get terrible’ The patient has not tried to do either of the preceding in the last 6 hrs because of perceived discomfort. Also when she tries to stand and move she has some vertigo type sx’s and occasionally the ‘rhythmic pounding’ returns. Airway, Patent, skin: pale, hot, dry, with some tenting, no lesions noted. Her appearance is clean and obese and the house is well kept and clean, like you would expect an avg middle class house to be. No rash, no nuccal rigidity, she can touch her chin to her chest fine. 0 facial droop, no pronator or arm drift, 0 slurred speech, no swallowing difficulties, intact sense of smell, = hearing, = grips, pupils track equally, are sluggishly reactive, at approx 6mm bilat, but pt notes she does have transient scatoma, and occasional diplopia. No aniscoria, no dosconjucate gaze or dolls eyes, no hemi paresis or paraesthesias. 0 JVD noted, 0 HJR, - Kussmauls sign, 0 palpable nodes, tracheal midline and thyroid palpable, no masses felt. Chest: = symmetrical CW expansion, S1-S2 without MRCEO, HR: 116 3 lead ECG: Sinus tach, 12 lead ECG shows same with just slight diffuse re-pol abnormalities, and borderline 1st degree HB, with no axis deviation but poor precordial R and T wave progression, FSBS:80, RR 26, Normal TV breaths, and normal regular normo-phasic respiratory pattern, LS’s clear all fields, with 0 whispered pectriloquy, bronchophony, or egophany, or vocal fremitus . ABD exam benign urine out put the day this started was normal, but she has had no PO intake in the last 24 hrs due to sx’s, and CC as described. Pt relates no PO intake over last 16+hrs, She has 2 weeks until she expects to beginning menses... 0 vaginal discharge, normal bowel mvmts. no new foods or detergent changes recently, no blood in vomit, no pain in calves and – hohmann’s sign Remainder of exam unremarkable. Her orthostatic v/s's are lying L arm B/P:190/100, sitting 208/100 standing 220/108... HR: 116 3 lead ECG: Sinus tach, 12 lead ECG shows same with just slight diffuse re-pol abnormalities, and borderline 1st degree HB, with no axis deviation but poor precordial R and T wave progression, FSBS:80, RR 26, Normal TV breaths, and normal regular normo-phasic respiratory pattern, LS’s clear all fields, with 0 whispered pectriloquy, bronchophony, or egophany, or vocal fremitus. During Txp your pt’s sx’s get better and her H/A is down to a 4, her nausea and dizziness, as well as ‘pounding in her ears resolve as well. You decide to continue with your 1 liter fluid bolus, and O2 and repeat your V/s’s and get L arm B/P of 132/80, HR88, RR20. Along with the previous questions, What’s next? Whats else would you like to know? Whats your DX? ACE844
MedicRN Posted July 15, 2006 Posted July 15, 2006 Looking at the pituitary gland..... What are the results of a Brain scan with/without gadalidium? What are her hormones levels (ADH, GH, prolactin, FSH, LH, etc)?
Ace844 Posted July 17, 2006 Author Posted July 17, 2006 "MedicRN," Labs WNL, and CT- Out here, ACE844
chbare Posted July 17, 2006 Posted July 17, 2006 She has a sodium of 120! Better watch out for seizures. This may be from the N/V and no PO intake times 16 hours. Any C/O tinnitus? I cannot rule out labrynthitis. We need to place a foley and monitor I/O and send a UA to the lab. Manual diff on the CBC? I would also like an ABG and along with that ABG a carboxyhemoglobin level. Continue with the fluids and oxygen and reassess after the liter bolus. Take care, chbare.
Ace844 Posted July 17, 2006 Author Posted July 17, 2006 She has a sodium of 120! Better watch out for seizures. This may be from the N/V and no PO intake times 16 hours. Any C/O tinnitus? I cannot rule out labrynthitis. We need to place a foley and monitor I/O and send a UA to the lab. Manual diff on the CBC? I would also like an ABG and along with that ABG a carboxyhemoglobin level. Continue with the fluids and oxygen and reassess after the liter bolus. Take care, chbare. "CHbare," U/A; Appearance dark and concentrated, no other abnormailities noted CBC: WBC: 10 RBC: 14 PLT: 380 HGB: 12 HCT: 38,000 DIFF: WBC (cells/ml) 10 Segmented neutrophils 56 Bands: 4 Basophils: .5 Eosinophils 0 - 3 (1 - 3%) lymphocytes: 28 Monocytes: 4 ABG (Normal): 7.35, PCO[sub:657668d5b7]2[/sub:657668d5b7]: 40, PO[sub:657668d5b7]2[/sub:657668d5b7]: 96, HCO[sub:657668d5b7]3[/sub:657668d5b7]:20,
chbare Posted July 17, 2006 Posted July 17, 2006 Ace844, the RBC's are a little elevated but everything else pans out. Several things to consider: 1)Menier's disease 2)Labrynthitis 3)Syphilis infection involving the inner ear 4)Lyme disease 5)Inner ear tumor ie acoustic neuroma With a history of HPV it is possible for her to have other STD's. -VDRL? -Hx of tick bite or living in an endemic area? -Hearing loss? Take care, chbare.
Ace844 Posted July 17, 2006 Author Posted July 17, 2006 Ace844, the RBC's are a little elevated but everything else pans out. Several things to consider: 1)Menier's disease 2)Labrynthitis 3)Syphilis infection involving the inner ear 4)Lyme disease 5)Inner ear tumor ie acoustic neuroma With a history of HPV it is possible for her to have other STD's. -VDRL? -Hx of tick bite or living in an endemic area? -Hearing loss? Take care, chbare. All excellent thoughts.., and not necessarily wrong, EXCEPT... IN THIS CASE :wink: Great effort, and you are all quite close! I'll give ya a hint this presentation is pathmneumonic..... ACE So any other tests, or DX's?
Ace844 Posted July 17, 2006 Author Posted July 17, 2006 As the transport progresses, and you get closer your partner gets cut off on the highway and has to swerve sharply to avoid a MVC. Shortly after this happens your patient reports that she hears a rhythmic, loud thumping in her ears and her vision is blurry..... Your partner sticks his head through to tell you he forgot to say that his convo with mom revealed not much, additionally you notice the pt's BMI is in the normal range and she has good dental health.
chbare Posted July 17, 2006 Posted July 17, 2006 Ace844, results of Dix-Hallpike testing? (rule out any history of cervical spine disorders prior to performing this test) Take care, chbare.
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