Three Case Studies: HELP!?!

[JasonA]

NC,

From your advice, and comparing it to what the book has on both of them, I went ahead and put "Possible Croup ( Maybe Epilogttits). Its not graded, so I am not worried about it. I remeber having croup once, and my parents said I had it a couple of times when I was really tiny. Ah, good times. Setting in a steamy bathroom, then outside when it was freezing.

On #2 I just went with an MI. Since he is on Lasix that does mean he has a history of heart issues. As an EMT-B, not being able to give Lasix, it isn't really important to figure out which one.

Thanks again!

(It looks like we are going to get snow again Thurs-Friday, so I might not have class anyway. Too bad I cant decide not to show up for appointments just because it is snowy. )

[scope2776]

She is allergic to sulpha drugs, takes lipitor 10 mg, lasix 10 mg and crestor 5 mg daily for hypertension and high cholesterol.

I'm surprised nobody caught this yet... but lasix is a sulpha drug!

I am all for teaching EMTs and Paramedics above and beyond the standard curriculum, but there has to be a fine line between extracurricular and extravagant. I think the questions may have been to put you in the mindset that many of your patients will have confusing and untreatable complaints with no correlation; but you are still going to have to formulate a treatment plan for when you are caring for them. This becomes a little simpler for EMT students because your scope of practice is limited and the tools you have to play with are fewer. So all of these patients are going to get a through SAMPLE OPQRST history, physical exam and 15 LPM O2 via NRB w/ TKO IV and supportive measures. These are questions that would challenge many first semester Paramedic students...

You respond to a 52 y.o. woman complaining of dyspnea, especially bad at night accompanied by a nocturnal productive cough and fatigue. Your general impression is that he is “sick”. You patient assessment reveals that she is tachypneic at 32/min and tachycardic at 110/min. She is also hypertensive at 162/102, A & O x 3 and confused, slightly pale with cyanotic lips, PERRL and has good sensory, motor and a cap-refill or 4 seconds. She feels nauseous, has some abdominal pain, sunken eyes, is weak and has been urinating frequently. She has not had much of an appetite but has been drinking tea, water and some hot chocolate. She is allergic to sulpha drugs, takes lipitor 10 mg, lasix 10 mg and crestor 5 mg daily for hypertension and high cholesterol. She is also diabetic type II and her BG levels read 72. She also takes nitroglycerine for her heart when needed and one baby aspirin daily. Upon auscultation you detect rales her lower lobes.

My take on this scenario is: defiantly reeks of CHF. At this point her body is still compensating for the decreased cardiac output. This pt could also have an AMI, and other fairly complicated cardiac complications. What's going to help this pt most is a hospital... I don't really find the glucose to troubling, if your chasing glucose levels as the cause of this pt's troubles you've missed the boat. It's just probably because she didn't eat today and only had liquids. Don't worry about it unless they have altered mental status... FOR YOU MEDICS: just curious - would you treat her pressure with nitro or lasix? Or would you be concerned with disabling her compensatory mechanisms and wait and see about the pressure???

You respond to an 80 y.o. man complaining of weakness. Your patient assessment reveals that he is tachycardic at 122/min, tachypneic at 36/min, A & O x 4, diaphoretic, pale, cool and clammy, peripheral edema, ascites and had a bout of epistaxis last night. He is allergic to penicillin, is on Zocor daily, Nitrostat when needed, has a nitro patch, baby aspirin daily, Albuterol 2 puffs morning and night, Flovent 1 puff morning and night, 40 mg lasix and a fiber pill daily. He has not had much of an appetite but has been drinking plenty of fluids.

I wouldn't be surprised if this is the guy with 3 previous MIs and a cardiologists number on speed dial. I smell AMI or just an old and busted heart. This is leaning more toward cardiogenic shock i think... check for swelling elsewhere, this guy has either a right sided MI or heart failure... a BP would be nice on this guy lol

You respond to a 3 y.o. female who’s mother is complaining of dyspnea accompanied by a harsh high-pitched cough. You patient assessment reveals that she appears sick is tachypneic at 38/min, tachycardic at 118/min normal blood pressure, is running a fever of 102 degrees has a cough and is drooling and is pale and has cyanotic lips. She is also congested and has signs and symptoms of a cold.

This fits nicely into the criteria for epiglottis. The pt is a little too old for croup, and the hx of fever is more favorable for epiglottis too. But as always, our patients don't read the textbook. This pt warrants aggressive, aggressive treatment. You don't want to do anything to increase anxiety for fear of completely shutting off the airway, but you do want to be on top of your treatments, very fine line. A helpful hint: if you do end up bagging these pts, try to bag them in the prone position, face down into your bag. This way you are using gravity to your advantage to pull the epiglottis down away from the trachea, and maybe you'll be able to get more O2 in. Maybe it will work, maybe it won't, haven't ever tried it myself. These are also the patients you DO NOT SUCTION!!!!! Don't do anything to aggravate that epiglottis... these are the patients we as medics only get one chance to tube. Scary stuff. Think about it this way, you can either spasm the glottis with a suction catheter or an ET tube, your choice. I choose the ET tube.

[JasonA]

SCOPE!

Dont confuse me! I think I am going to have to stick with TB for the first one. For one, it explains her cough. She also has a history of heart problems. Knowing my instructor, she wouldnt give us two heart problems at the same time. TB kinda feels right. You are right, I did miss the boat. I was trying to make it way too complicated, and out of ignorance, didn't see what was really going on.

I will argue with you on the have for croup. If I remember having croup, then it had to be when I was somewhere in the 4-6 range. Maybe a little older. Just shows ya that is doesnt always follow the book.

You threw out a bunch of information that is alittle out of my range, and I am sure we wont cover. So, thanks. The more I learn the better.

[scope2776]

You didn't miss the boat out of ignorance, just a little tunnel vision. Even the best of us still have trouble with that...

You have a great attitude! And your participation here shows that you care about gathering more information than can be found in the book or taught to you in class. This will be the mark of a successful career in EMS and quality patient care if you continue this tradition of above and beyond your education from class. A good EMT or medic will never stop learning. The minute you become complacent in this job is the minute you become a dangerous EMT or medic. And there is a difference between complacence and confidence.

It's not out of your range, you just haven't been exposed to it yet... lol

[chbare]

Furosemide is in fact a sulfonamide, however, minute structural differences exist when you compare sulfonamide abo's and non abo sulfonamides. While cross reactions are a concern, this is not absolute. In addition, "allergy" is an often misused term. What reaction did this patient have? Many people will take a med, develop nausea, and assume they have an allergy. If possible, asking about the "allergy" and about how the patient reacted can provide additional information.

Take care,

chbare.

[p3medic]

#3: Definitely epiglottitis. Croup is caused by a bacterial infection, and epiglottitis is viral. This child had a cold, which is usually viral as well.

epiglottitis is almost always caused by bacterial infection, croup is viral.....

[AZCEP]

epiglottitis is almost always caused by bacterial infection, croup is viral.....

Drat it.

I suppose I should have looked deeper than Haemophilius influenzae B. I jumped to the conclusion that "flu' meant virus. Didn't even consider it to be a bacteria. Thanks for making me look it up again.

[ncmedic309]

Might want to check that again ncmedic309. Epiglottitis is viral, croup is bacterial.

What? There's nothing to check, I had it right the first time! :wink:

In most cases, Croup is caused by a virus. There have been cases of croup that have been linked to a bacterial infection, but more times than none it's caused by a virus. Epiglottitis is almost always bacterial. Which onsets quicker - a viral or bacterial infection? In the case of croup (viral) the incubation period is usually 2-5 days. Epiglottitis which is bacterial has a rapid onset with little to no warning.

In regards to remembering the difference between viral and bacterial etiology - I was taught this:

Croup (short word) is Viral (short word)

Epiglottitis (long word) is Bacterial (long word)

I know, kind of silly, but it seems to help students differentiate between the two when it comes to etiology.

[chbare]

Just a side note of useless knowledge. With the widespread use of the HIB vaccination, epiglottitis in children is most often the result of G+ cocci. (streptococcus pyogenes & staphylococcus aureus) Sorry, I do not have the ability to change the text style for you microbiology sticklers.

Take care,

chbare.

Take care,

[ncmedic309]

You can also add streptococcus pneumoniae to that list, it's also a common gram positive etiology of Epiglottitis...