Neuro Pt

[MAMed]

I had a funny call the other night and would like to know if anyone has any ideas.

Dispatched for a psych with PD on scene. Arrive to find a 40 yo f out with FD BLS rescue unit. Pt is behind the wheel in a parking lot on O2 by NRB.

PMHx: hypothyroidism on synthroid. pt has chronic HA and ABD pain. Pt has "numb face" x 2wks.

FD cleared PD off scene before I got to talk to them. FD said the pt broke down crying when they tried to assess mental status. When I assessed the pt she was A/Ox4 but seemed a little off. I did a CN exam. The pt failed an H-test because she could not look upper right on repeated attempts. pt could not fully smile for facial nerve exam and swayed when performing a Romberg test for the auditory nerve. No pronator drift but her hands shook. Pt was HTN with no Hx. Mild slurred speech but could be normal. Denied ETOH or drug use. Monitor showed sinus tach at just over 100BPM. The pt initially refused transport unless I would take her to a hospital that was close to 90 miles away with a level 1 and thee level 2 in town but med control convinced her to go.

This could be a CVA or TIA but struck me a neuro. Does anyone have any ideas?

[chbare]

Did you check her BGL? A quick, easy, and often overlooked assessment.

Take care,

chbare.

[OVeractiveBrain]

Psych Hx?

Past Medical History?

Meds?

Allergies?

Sounds neuro to me. From what youve reported Id treat it like a stroke. Shes got + rhomberg findings and is hypertensive with tachycardia.

A number of things could cause her to be excited which could cause the VS findings. That being synthroid. Though hyperthyroid, to my knowledge, does not include stroke like symptoms. It may have lead to a CVA, but should not mimic symptoms.

I think you might not be letting on all your findings. I think what youre debating is whether or not this patient was really a psych or if she was having a cerebral event. With the data you reported, I would treat her as a stroke. If shes had these symptoms for 2 weeks (outside of 3 hrs), she could go to whatever hospital shed like: shes screwed anyway. But since that is unlikely, and shes got obvious symptoms, Id get her to the nearest hospital.

If she is a stroke: She needs to settle down and determine when her symptoms actually started. If shes an acute, shes probably a good candidate for fibrinolytics (young, no hx, no surgeries).

Ive brought in a drunk with ALS for a stroke, until we breathalized him at the ER at .350. But if they are presenting at all with stroke symptoms, treat it as a stroke. (btw, yes he smelled of alcohol, but he denied its use and it was 9am).

[MAMed]

Yes I did. Sorry for leaving that out. I don't remember the number but it was within normal limits.

[MAMed]

Ov I do not need to be told what I thought. If I did not say I thought she was a psych then I did not (BTW I already have a degree in psychology). The only finding I left out was the CBG which I did by mistake.

Thank you for your input though

[Dustdevil]

Ov I do not need to be told what I thought. If I did not say I thought she was a psych then I did not (BTW I already have a degree in psychology). The only finding I left out was the CBG which I did by mistake.

MA, there was no reason to read anything personal into that. People do that here all the time. They come post a scenario and ask us for input, then they come back and feed us more information as the scenario unfolds. It's actually the norm here, so you can't blame us for thinking it. After all, you DID leave something out, albeit accidentally. We won't know what else you are leaving out unless we ask. Just like the BGL thing, you won't know what you have forgotten unless we ask about it.

You posted a beautiful scenario, and obviously did a great assessment. Nobody's attacking you or questioning your competence. We're just trying to get into your scenario.

[OVeractiveBrain]

THen whats the question with the case?

Positive Rhomberg test in a 40yo female without any contraindications to fibrinolytics is pretty clear cut. Head straight to the nearest ER and get her a CT scan. The only thing left is to determine an actual time course to see if fibrinolytics are viable.

CVA/TIA is neuro. Cranial Nerve damage should be treated as a stroke until proven otherwise. Theres nothing in her hx, all, or meds to suggest theres anything else going on. Again, rapid changes in dosage of synthroid can lead to CVA / MI but would not simulate its symptoms.

[MAMed]

"I think what youre debating is whether or not this patient was really a psych or if she was having a cerebral event."

I did post looking for constructive critism but the above statement is what set my hackles up, not the critism on assessment or treatment

Sorry I have not posted in a while and forgot how to quote other posts.

[emt322632]

I'd consider this a possible CVA or TIA until proven otherwise.

No way to really r/o in the field, so she gets the full ALS tx and transport to the nearest hospital as many others have said.

Good scenario.

[MAMed]

I want to apologize for the digression into bickering. But the symptoms of the numb face x 2wks is what really threw me for a loop. Any one heard of this associated with CVA or TIA