chbare Posted July 14, 2006 Posted July 14, 2006 I want to do something a little different. In this scenario you can have all of the diagnostic tools and cool guy procedures, however, I would like you to give the rationale behind the tests and procedures you perform. For all of you BLS providers, this scenario can be solved if you use some of the most important skills out there. These skills are not beyond the scope of a BLS provider. Here goes. You are dispatched to the scene of a 29 year old male who complains of feeling very tired and weak with bilateral knee pain. What would you like and why? Take care, chbare.
Ridryder 911 Posted July 14, 2006 Posted July 14, 2006 A weight... so I can see if I have to walk him or I will need the squad to assist me.... Okay, good H & P ... Knee pain huh? Any other associated symptoms? Occurrence, time, activity, PMHX, any OTC treatments, NSAIDS abuse, related history of this occurrence, trauma, arthritis, change in pain, limited mobility, substance abuse, Diabetes, old sports injuries, Diet, exposure to chemical, sexual activities or Hx. of STD, smoker, hx. of gout, tick or insect bites, previous surgeries ? etc... Exam: joint character, swollen, red, femoral, popliteal, distal pulses, if no trauma- pain upon movement, R.O.M., orthostatic v.s. check, check skin turgor, conjuntiva for possible anemia, sclera for icterus, hepatic reflex to see if there is liver flap, perform a pretty darn head to toes thorough assessment. Okay Test & rationale. Baseline v.s . won't know his beginning without Tilt-test- a change in points may indicate fluid shift, or loss from anything form bleed, anemic, to hx. of diarrhea, or vomiting. A real thorough physical exam with as much hx. you can obtain, although this maybe a routine B.S. call, it could also be a 101 other ailments....NEVER ASSUME ( and we know assume stand for right?) FSBS- check his glucose level, not unusual for onset DM to have these symptoms, of fatigue, general malaise, even joint pain Lab- Let's start with a U/A to check protein, specific gravity, uric acid level, CBC- have to see what this H & H is, as well as his white count and if there is a shift or not (Bacterial versus Viral- right versus left) CMP- metabolic profile to check all those cation and anions that all you Paramedic & Intermediates thought was not important. UDS or Tox. screen- be sure our gentleman may be hiding something Cardiac Profile- strange yes, but if he has a outstanding history ... who knows? PT/PTT/INR- to see how fast he is clotting or diluted... oh, what the heck let's get an ammonia level as well... If we do find tick bites, fever.. do a RMST spot ... Mono -spot... ************God, I feel like a resident ! Of course, this all dependent on the exam and history.. probably eliminate a lot of the test. after recieving more H & P. Knee x-ray ... dependent on the exam if others... Treatment.. probably start out with a liter of fluid. Dependent on BP as well.
chbare Posted July 14, 2006 Author Posted July 14, 2006 Ridryder 911, he can walk on his own. He states the pain started a few days ago and has gotten worse since onset. No PMHX and no history of trauma. Denies smoking or drug use. He states he does not think he has been bitten by anything. The exam is unremarkable except the patient does look a little pale and you do not note anything significant with his knees. The pain is arthritis like when he describes it and the pain increases with movement and ambulation. There is no evidence of trauma and he has full ROM. You do not notice any neuro deficits. He states the only thing out of the ordinary was he noticed a red rash to his lower right leg that started about 2 weeks ago while on vacation but it has completely resolved. Base line VS: P- 90 reg, RR- 20 N/L, B/P-128/88, Temp-99, Pain 8/10, O2 sat-98% R/A. You got some basic labs back, but will have to wait for the others. NA-140/ K-4/ CL- 101/ Co2- 25/BGL- 115/ BUN- 8.1/Creat- 0.8 WBC 10/Hbg 12.6/ Hct 40.2/Plt 220 Tilts, UA, and UDS are negative. (EDIT: Fish bone lab diagrams would not present properly.) The 12 lead shows a sinus rhythm with borderline first degree AV block. Ridryder 911, you are thorough and informative as always. Anything else? Take care, chbare.
future medic 48_234 Posted July 14, 2006 Posted July 14, 2006 With this patient, I'm guessing possible bilateral osteoperosis or infection developing in the knees, maybe the knees could be pinching blood vessels since it may be pain related. I'm not sure about being pale. I ould put the ptient on 15 lpm non-rebreather (be on the patients' behalf, not the pulse-ox )
chbare Posted July 14, 2006 Author Posted July 14, 2006 Future medic 48_234, I cannot fault you for aggressive airway management. The pain leads you to suspect osteoporosis versus infection? Is there anything in this patients history that you would like to know more about? More labs come rolling in: PT-12, INR- normal per your labs controls, PTT-35, NH3-13, tyrponin 1-0, tryponin t-0, myoglobin-35. Your partner orders an ESR for the heck of it and you get a result of 40. Take care, chbare.
AZCEP Posted July 14, 2006 Posted July 14, 2006 Distal circulation? Ultrasound of the popliteal/femoral arterial beds The temp really doesn't scream out an infection yet. Is there any streaking from the site? Red rash on one, but not the other?
chbare Posted July 14, 2006 Author Posted July 14, 2006 AZCEP, the distal circulation to both legs are intact. US is negative and circulation is intact to the vessels of both legs. You do not note any redness on the patients legs. He tells you that he did have a red rash about two weeks ago while he was away from home on vacation but that the rash went away. He also states that he noticed that he started feeling a little fatigued around that time as well. Take care, chbare.
NYAEMT-I Posted July 14, 2006 Posted July 14, 2006 Is there any history of Rheumatoid arthritis in his family? Do his knees feel hot to the touch, and is the pain there more after sitting around and then getting up and being active? Also with the rash on the lower leg what did it look like? I would like to test him for Lyme disease. NYAEMT-I
chbare Posted July 14, 2006 Author Posted July 14, 2006 NYAEMT-I, no history of any medical problems. Knees are not hot to the touch. The knees hurt more with activity. He cannot remember exactly what the rash looked like other than it was a red circle. You may be on to something with the Lyme disease test, however, you need to give me your rationale for ordering this test. Are there any other questions that you could ask him that may help to further confirm your suspicions? Take care, chbare.
future medic 48_234 Posted July 14, 2006 Posted July 14, 2006 Future medic 48_234, I cannot fault you for aggressive airway management. The pain leads you to suspect osteoporosis versus infection? Is there anything in this patients history that you would like to know more about? More labs come rolling in: PT-12, INR- normal per your labs controls, PTT-35, NH3-13, tyrponin 1-0, tryponin t-0, myoglobin-35. Your partner orders an ESR for the heck of it and you get a result of 40. Take care, chbare. Heres' what I'm thinking: I suspected osteoporosis in the knees causing the pain. The infection was another posibility that may also cause the pain. Could the Pt be loosing elasticity in his knees? Inflamation of the knees? Can you give me SAMPLE, and OPQRST? I'm only a basic. I don't understand the following what was said about the lab tests: More labs come rolling in: PT-12, INR- normal per your labs controls, PTT-35, NH3-13, tyrponin 1-0, tryponin t-0, myoglobin-35. Your partner orders an ESR for the heck of it and you get a result of 40. NA-140/ K-4/ CL- 101/ Co2- 25/BGL- 115/ BUN- 8.1/Creat- 0.8 WBC 10/Hbg 12.6/ Hct 40.2/Plt 220 Tilts, UA, and UDS are negative. Can you please explain these? I would like to know what they are and what they mean.
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