Dustdevil Posted June 26, 2007 Posted June 26, 2007 Pulse-62 BP-90/60 Resps-24 What else? How about the rest of her vital signs? You're in a nursing home. Even if your agency sucks and doesn't carry thermometers, I bet you can find one there. Pulse Ox? And don't get tunnel vision on this hypoglycaemia thing until you've done a thorough examination for other conditions.
jwraider Posted June 26, 2007 Posted June 26, 2007 What dust said complete the vitals... SP02 maybe temperature and a detailed assesment.. DCAP_BTLS.. Looking for things we couldn't see while she was in bed under the blankets. FOr example how does this person go to the bathroom? Foley? Diaper? Any info on urine output or bowel movements? How do her legs look? Also maybe a better Hx although sometimes a SNF doesn't have a nurse who speaks english can we pretend this one does? =) What was she doing earlier in the day? Activity? oral intake? Are any of these symptons new or are they chronic? (Lung sounds). I'm assuming the care at the facility is minimal if their only complaint was she was unresponsive and didn't report on the rest of her condition.
ERDoc Posted June 26, 2007 Posted June 26, 2007 Let's think of the differential of hypoglycemia. Anyone wanna try it? What about the pt that we already know either supports or refutes the things on the ddx?
Rezq304 Posted June 26, 2007 Author Posted June 26, 2007 I apoligize, SpO2 of 92% on RA. SpO2 up to 99% on 15L O[sub:7a2fbddd32]2[/sub:7a2fbddd32] by NRB. Temp orally of 99.1[sup:7a2fbddd32]o[/sup:7a2fbddd32]. Lung sounds do not improve upon placing patient in full fowler's position. Repeat BGL after Dextrose of 184. DNR is on board, but your patient is not in cardiac arrest. Patient begins to become alert to voice when you note a small section on her paperwork that denotes her med Hx to include Alzheimer's & Dementia. Still looking for a complete meds list that would've clued you into this sooner. No Hx of Diabetes and no Hx of Insulin admin.
Rezq304 Posted June 26, 2007 Author Posted June 26, 2007 What dust said complete the vitals... SP02 maybe temperature and a detailed assesment.. DCAP_BTLS.. Looking for things we couldn't see while she was in bed under the blankets. FOr example how does this person go to the bathroom? Foley? Diaper? Any info on urine output or bowel movements? How do her legs look? Also maybe a better Hx although sometimes a SNF doesn't have a nurse who speaks english can we pretend this one does? =) What was she doing earlier in the day? Activity? oral intake? Are any of these symptons new or are they chronic? (Lung sounds). I'm assuming the care at the facility is minimal if their only complaint was she was unresponsive and didn't report on the rest of her condition. Only report given was minimal. I ran this as an ALS intercept for a BLS truck. They asked the majority of the questions posed to me & were not given an answer.
Dustdevil Posted June 26, 2007 Posted June 26, 2007 I'm curious as to how (and why) you got an oral temp on an unconscious, unresponsive 92 year old. :? Are you confident in that temp? And would you consider that a fever?
Rezq304 Posted June 26, 2007 Author Posted June 26, 2007 I'm curious as to how (and why) you got an oral temp on an unconscious, unresponsive 92 year old. :? Very carefully...oral was the best option at the time & pt did feel afebrile to touch. Are you confident in that temp? Not very And would you consider that a fever? No
rocket Posted June 26, 2007 Posted June 26, 2007 Something had to use up all that sugar. An infectious process is what springs to mind for me as a possible candidate. There are a few things about her that might make the presentation a bit atypical: (1) Her age (2) her cardiac meds. The tachypnea could be related to an infectious process (e.g., pneumonia), the hypoglycemia, or it could be something else such as a metabolic issue. Is there any evidence of kindey problems, etc in her records? -Trevor
Just Plain Ruff Posted June 26, 2007 Posted June 26, 2007 when is the last time that she peed? What does her urine look like? Is she catheterized - if she is and shes in a nursing home then 95% probability is that she has a Urinary Tract infection.
rocket Posted June 26, 2007 Posted June 26, 2007 Forgot to add: I agree with jwraider on the need for a very detailed head to toe physical exam. She's not much of a historian given her current condition and the handoff info from the facility/crew seems to be less than voluminous. Any interesting findings on the detailed head-to-toe? Since she was an intercept I know you didn't get the chance to look at the surroundings...this makes the physical exam even more important IMHO. Also, does the monitor have etCO2 monitoring? Maybe we can slip in one of the measuring cannulas? If so how does the waveform and numbers look? -Trevor
Recommended Posts