Re: Case Scenario

[Guest guest]

Gene,

I'll take a run at it before visiting the web site.

Chvosteck sign is spasm of the oris muscle produced by tapping just anterior to

the ear (over the 7th cranial nerve). Trousseau sign is carpopedal spasm

produced by inflation of the sphygmomanometer on the upper arm. Both signs and

the symptoms you mention indicate possible TS (tetany syndrome). The usual

suspects are hypomagnesaemia and/or hypocalcaemia. The presence of Trousseau

sign is indicative of a chronic case. Other S & S to look for are headache,

dizziness, brittle finger and toe nails and disrhythmias. The patient is just as

likely to suffer constipation as diarrhea. Diagnosis would require labs to

determine serum Mg and Ca levels with treatment appropriate to the results.

How did I do?

Donn

[texasems-L] Case Scenario

A 50's y/o female C/O of worsening paresthesias in her arms and legs X5 days

and a one-day history of cramps in her hands and facial muscles. She had also

had diarrhea intermittently for two weeks. She reported no alcohol ingestion.

Physical examination revealed mild hyperreflexia, Chvostek's sign, and

Trousseau's sign.

How do you check for Chvostek's and Trousseau's signs and what's the

significance of positives?

If you'd like to cheat, go to:

http://www.nejm.org/content/2000/0343/0025/1855.asp

Gene Gandy

[Guest guest]

Donn,

You win the MILLION! Great job.

Gene G.

[Guest guest]

Chvostek's signs and Trousseau's signs are also associated with tetany.

Tetany is a nervous disorder seen with intermittent spasms that can involve

the extremities and also is related to numbness and tingling of the

extremities. To test for Chvostek's signs tap over the facial nerve on one

side of the face to see a spasm of the facial muscles. To test for

Trousseau's sign, take the affected extremity and press down on the primary

vessel and nerve. This should produce a spasmic type contraction of the

muscle and is a sign of tetany.

Joanna LP

[Guest guest]

Gene:

Chvostek's sign is elicited by tapping on the facial nerve on one side of

the face. Trousseau's sign is elicited by by occluding arterial blood flow

in one arm for five minutes. A positive Chvostek is a spasm causing

twitching of the nose or lip in response to the tap. A positive Trousseau's,

is observed contraction of the hand and fingers when the blood flow has been

occluded for five minutes.

These are among the signs suggestive of tetany, often due to hypocalcemia.

This can be from various causes including Vitamin D deficiencies,

malabsorption from the GI tract, phosphorus poisoning, certain kinds of bone

neoplasms, and problems with the parathyroid hormone that prevent proper

production of parathyroid hormone (PTH). About 500 - 1000 mg of calcium

chloride might go real nice about now.

BTW. In case anyone actually thinks I already new about these diagnositics,

NOT GUILTY! As any good paramedic should do, I immediately looked these up

in my reference resources and now I have new tools I didn't have before and

have not continued in my blissful ignorance. I may never use the

information. On the other hand, it may be just the thing to help a patient

and make all of us look more knowledgeable and competent one of these days.

Thanks, Gene, for tossing out a challenge.

Dave

To: <egroups>;

Sent: Wednesday, December 20, 2000 7:29 PM

Subject: [texasems-L] Case Scenario

> A 50's y/o female C/O of worsening paresthesias in her arms and legs X5

days

> and a one-day history of cramps in her hands and facial muscles. She had

also

> had diarrhea intermittently for two weeks. She reported no alcohol

ingestion.

> Physical examination revealed mild hyperreflexia, Chvostek's sign, and

> Trousseau's sign.

>

> How do you check for Chvostek's and Trousseau's signs and what's the

> significance of positives?

>

> If you'd like to cheat, go to:

> http://www.nejm.org/content/2000/0343/0025/1855.asp

>

> Gene Gandy

>

>

>

[Guest guest]

Dave,

Well spoken. Gene is forever challenging our boundaries and testing our comfort

zones. We are all the better for it. Some will ask why a paramedic needs such

information. However, as you said, you never know when some bit of seemingly

trivial information will be needed.

My knowledge of the question came from a wonderful Vietnamese physician just two

years ago. I had a 60ish YO patient present C/O palpitations. ECG revealed a

wide complex V tach with occasional multifocal PVC's. He was hyperthermic,

hypertensive and hyperpneaic. He also appeared dehydrated with skin tenting.

While taking a PMH he described constant abdominal cramping and intermittent

bouts with first diarrhea then constipation Q 30-plus days, recent onset

cramping of the feet and hands, headache, dizziness and painful cracks appearing

in both finger and toe nails. None of this worried him until his heart started

jumping out of his chest. The man was a life-long alcoholic and was accustomed

to most of the symptoms he had been suffering. I contacted the physician I

mentioned for some direction. Following several questions he directed me to

perform tests for Chvostek and Trousseau sign. Both were positive. Since we were

in a storm situation and all transportation was grounded, his orders were fluid

bolus NS 500 ml wit IV antibiotics followed by continuous infusion MgSO4 0.5

grams / hour X 24 hours. Over the next two days the man plumped up a bit and his

ECG became more normal. The extremity cramps subsided and the headache and

dizziness resolved. The abdominal cramps never let up though. Once the storm

cleared I sent him to hospital with the IV's still hanging. He was diagnosed

with diverticulitis and went to surgery. The TS was apparently the secondary

result of hypomagnesaemia induced hypocalcaemia resulting from fluid loss and

malabsorbsion.

This was a great learning experience and the same physician talked me through

several other tough cases. I've retained all my notes and when Gene presented

this case I ran to my bookcase and thumbed through several notebooks before

finding the above case. A paramedic can never learn too much.

Best regards,

Donn

Re: [texasems-L] Case Scenario

BTW. In case anyone actually thinks I already new about these diagnositics,

NOT GUILTY! As any good paramedic should do, I immediately looked these up

in my reference resources and now I have new tools I didn't have before and

have not continued in my blissful ignorance. I may never use the

information. On the other hand, it may be just the thing to help a patient

and make all of us look more knowledgeable and competent one of these days.

Thanks, Gene, for tossing out a challenge.