Patient Advice

[Steven]

I have a question about a patient I saw the other day.

I was dispatched on a 81yo sick patient. Upon arrival she complained of being weak, dizzy, and sweating. She had no cardiac history, no respiratory history, and took no medications. Her vitals were great, blood sugar at 112, and she had no medical history. She was cold, extremely sweaty and pale when I got there. After sitting a while she felt better, then everything returned when she stood up. I had her sit back down and she felt fine again. ALS responded and found nothing irregular with the patient (by assessment and EKG), and the patient signed a refusal. I transported her home and she was fine, and was fine the next morning when I saw her.

Can you all offer any advice on what could have been her problem? I was completely stumped and had no idea what needed to be done, aside from basic BLS skills. I expected to find something abnormal when assessing the patient, but nothing was present.

Thanks for any help

-Steven

[Lone Star]

I have a question about a patient I saw the other day.

I was dispatched on a 81yo sick patient. Upon arrival she complained of being weak, dizzy, and sweating. She had no cardiac history, no respiratory history, and took no medications. Her vitals were great, blood sugar at 112, and she had no medical history. She was cold, extremely sweaty and pale when I got there. After sitting a while she felt better, then everything returned when she stood up. I had her sit back down and she felt fine again. ALS responded and found nothing irregular with the patient (by assessment and EKG), and the patient signed a refusal. I transported her home and she was fine, and was fine the next morning when I saw her.

Can you all offer any advice on what could have been her problem? I was completely stumped and had no idea what needed to be done, aside from basic BLS skills. I expected to find something abnormal when assessing the patient, but nothing was present.

Thanks for any help

-Steven

First off, can you define 'her vitals were great'?

Second, I'm presuming that 'everything returned', you're referring to the original complaints?

What was she doing when the original symptoms occurred?

I'm leaning towards a drop in blood pressure when she stood up causing the symptoms to reappear. The sudden drop in blood pressure would explain the 'dizzy and weak' part, and a release of adrenaline could explain the diaphoresis.

When the symptoms returned, did you by chance reassess the vitals?

[medic001918]

ALS responded and found nothing irregular with the patient (by assessment and EKG), and the patient signed a refusal. I transported her home and she was fine, and was fine the next morning when I saw her.

I'm confused at this statement. How could the patient sign a refusal, but still require transport home? Did she end up going to the ED anyway by some other means? Just looking for some clarification.

As for the change when she stood up, it sounds like she may have had some orthostatic changes in her blood pressure and heart rate. This can indicate anything from an underlying cardiac issue to dehydration. Without knowing more about what led up to the call, it's difficult to say for sure what's going on. A patient that's 81 years old can have many undiagnosed etiologies that will effect them and cause different signs and symptoms.

It sounds like when she changes position, that her body can't keep up with the demands that it has.

Shane

NREMT-P

[Steven]

Just for clarification... the patient lived at another building in our facility, but was at a friends house playing cards. That's why I transported her home (to her house from her friends house).

Her original set of vitals upon arrival were...

BP 135/76

Resp Rate 16

SpO2 - 98%

Pulse 75

Cold/Pale/Sweaty

When she stood up and the symptoms/signs returned, I found the following:

BP 138/78

Resp Rate 16

SpO2 - 99% on 3L O2

Pulse 82

Cool/Flushed/Sweaty

One of the downfalls to the call and for her signing a refusal is due to her saying she was a registered nurse. While not a valid excuse, she was AOx3 and was capable of making the decision to refuse. We encouraged her to see her PCP the next day to get checked out.

Upon onset, she was walking from an apartment into a hallway on the way to her vehicle. There were no environmental changes present that could have influenced her condition.

Thanks again everyone, I really appreciate your help!

-Steven

[medic001918]

Her saying she was a registered nurse shouldn't have any impact on the refusal aspect. If she was alert and oriented, and had everything explained to her then it's within her rights to refuse regardless of her present or past occupation. It just might make it easier/harder (depending on personality) to convince her that she should go get checked out.

If the onset was under exertion such as walking, and the symptoms resolved with rest and only to return with exertion again (standing up is exertion for some); than I would consider that a form of orthostatic change potentially. Orthostatic vital signs are a great way to see how well the body can compensate for a change in demands. Unfortunately, I don't think they're done often enough prehospitally. If orthostatic's weren't taken on scene then there is no way to know for sure if there were changes. Was there any recent sickness such as a cold/flu? Fever? Etc? She may have been simply dehydrated if she hasn't been eating and/or drinking well. And like mentioned earlier, it could be indicative of an underlying cardiac or nervous system problem. It's tough to tell and even a 12-lead isn't the best indicator of if there's something going on or not.

[Ridryder 911]

I do hope that she was encouraged to seek medical advice and not just "brushed off". Even as a former RN, she needs to be told the potential risks. Anyone having a period of diaphoresis, cold sweats, needs to be evaluated even though it might be transient in nature, it could be a precursor to something.

Field evaluation is very limited, and everything we have for diagnostics is not in-depth enough to "rule anything out".

R/r 911

[ERDoc]

This case just reeks of something bad. Elderly people are not to be trusted. They will never present with the classic symptoms of anything. They do not mount the typical physiologic responses to anything. Obviously you can't force her to go, but she should have been exhaustingly encouraged. Elderly people are landmines waiting to be stepped on. Fear the elderly person with a fever or vague symptoms.

Pick up a copy of Harwood-Nuss (Clinical Practice of Emergency Medicine) and read the chapters on the weak pt and abd pain in the elderly. They will scare the hell out of you.

[AZCEP]

If she got dizzy when she stood up, her orthostatic vital signs were positive. There was no need to take a full set to figure this out. With the age alone, she should have been "exhaustively encouraged" to seek medical assistance. (Nice one there ERDoc, )

Alert and oriented, but can't stand up? She needs evaluated further. I'd venture hypovolemia, simply because it is very common. 81 y/o and on no medications? Everyone starts sometime, and this patient may be telling you from her presentation that it is time for her.

Very easy to become complacent with this one. Fear the female over 45.

[Dustdevil]

If she was on medications (which you say she took none), then an experienced clinician *might* be tempted to approach this in a semi-relaxed manner as a problem with her cardiac or antihypertensive meds that needs to be worked up and worked out. However, in a field setting you can make no such assumptions, even if you are an experienced clinician. I agree that this scenario just has disaster written all over it. Most of the differentials for this patient have the potential for very seious sequelae. She very definitely needs to have a comprehensive in-patient work-up to determine the problem before your next trip with her turns into an ME run.

And remember, not all RNs are good diagnosticians, and being an RN does not make you immune from denial.

[1EMT-P]

I would have encouraged this patient to go to the hospital for an evaluation, given her chief complaint, signs and symptoms. The list of possible causes are endless.