Guest guest Posted December 2, 2001 Report Share Posted December 2, 2001 Yes that is an unusual scenario and as far as the treatment goes I'll leave that to the Doctors at the hospital. I know that sounds simple, but as far as I'm concerned this pt needs Hospital care. As for the Prehospital Care goes, O2, IV and EKG is what I would do as a field medic. Now, what the problem is with this pt, I would give a Presumptive Diagnosis of Poss CVA, and Poss DTs. That would be my best guess. So, this pt needs a Hospital for a CT Scan and further lab work and I would continue Cardiac Studies, but as far as Prehospital care goes, supportive measures only and continue to monitor your pt. That one will make you think instead of just react, LP Instructor FTO > Here is a rather unusual scenario taken from a real life situation. See if you can wade through the conflicting history and S & S as well as the paramedic involved did. > > > > Good luck, > > Donn > > > > ------------------------------------- > > > > A paramedic is working as an assistant to the physician at a rural clinic. Her job is to triage patients, perform initial exams, and route the patient either to the PA, the physicians, or recommend transfer to a facility with better resources. > > > > A 62 YO female patient presents to the clinic. She is ambulatory but moves with some difficulty, assisted by her daughter. Her chief complaint is back and neck pain. Upon questioning she reveals that she started feeling fever and flu-like body aches three days ago, but has developed no upper respiratory symptoms consistent with influenza. She advises that the aches have gotten progressively worse and that now her back and neck cramp " pretty regular " . She has had difficulty rising from a sitting position and can find no position of real comfort. Today her throat started " acting up " and was unable to eat her soup. > > > > The patient appears unkempt and is wearing wrinkled, soiled clothing. As she speaks she is sitting erect on the exam table arching her back, using one hand to rub her neck. The paramedic notices the patient's face is twitching occasionally on the left side and that she is turning her head slightly to that side with each spasm. The paramedic also notices a small, partially healed, undressed wound on the anterior surface of her left wrist. The patient advises that she burned herself while frying bacon " about ten days or two weeks ago " , but that it doesn't hurt anymore. When asked about medical history she states that she had a recent bout with vomiting and for which a physician at another clinic administered " a shot in my butt " and prescribed metronidazole and Donnagel PG. A telephone call to the other clinic verifies the patient was treated and released for gastroenteritis of unknown etiology and the injection to be promethazine HCL. The patient claims that the problem resolved " a few days ago " and she hasn't thrown up since. Other medical history includes hypertension, asthma and multiple minor wounds and fractures resulting from a hard life on a farm. > > > > Among her other medications are aldactone, Zyloprim, lasix, and a half-empty bottle of metronidazole. She states that the " other " doctor has had her on " all sorts of dope " from time to time and that most of it " makes me sick " . Her daughter states that she has half- empty pill bottles all over the house and that she does not take her medications according to doctor's orders. The patient claims that she is allergic to aspirin and penicillin and all " them cains " . The daughter states that her mother has not eaten since yesterday, taking only a few sips of fluid today. She has not been able to take her medications today due to an inability to swallow. She smokes " a pack or so " of unfiltered cigarettes daily " when I can afford 'em " , and she drinks only a little of the wine that she makes herself. Her daughter tells you that her alcohol consumption is greater than the patient admits, and that her mother's homemade wine " scares " her. > > > > Examination reveals an irregular pulse of 104, blood pressure of 152/102, respirations non-labored at 20, oral temperature of 101.9, and pulse-ox reading of 96. Her lung sounds reveal minor wheezing in the upper quadrants bilaterally. Ears, nares, mouth and oral pharynx are unremarkable. Because of the irregular pulse the physician orders a 12-lead, which shows irregular tachycardia, QRS width of 0.15 sec., rSR complex in V1, wide S wave in leads I, aVL, V5 and V6. Head to toe exam reveals that she is indeed trismic and all extremity joints are painful to palpation. Her feet and ankles are very slightly edematous. Palpation of her back elicits frank spasms and pain. She claims that she didn't feel bad enough to see the doctor when her daughter insisted she come, but that " Now that you have been poking on me " , she feels worse and claims to " hurt all over " . > > > > > > Does this patient need referral to another facility, or can we treat her successfully here? > > What potential etiologies must you sort through to make diagnoses? > > What did the 12-lead findings indicate? > > Were the 12-lead findings pertinant to the chief complaint? > > What is the most relevant finding from the history and physical? > > What disease process is most likely the cause of the chief complaint. > > What initial therapy would you recommend? > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 2, 2001 Report Share Posted December 2, 2001 Whith the progressive dyshagia and other neuro findings, complicated by the EKG changes and fever I would certainly refer this patient for tertiary evaluation. Until further ruled out, this might be 1) tetanus, 2) Rocky Mountain Spotted Fever, or 3) Wood alcohol poisoning from the " wine " . There are several subtle signs that of themselves, could send you down any beaten path. At the risk of hearing hoof beats and thinking zebras, the variety of symptoms described must have added up to a really sick patient, shortly after this scenario. God, bless America No evil can happen to a good man, either in life or after death. Plato (428 BC - 348 BC), Dialogues, Apology Larry RN NREMTP Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 2, 2001 Report Share Posted December 2, 2001 Has the lady ever had a tetanus shot????? Just wonderin', Carla Unusual Scenario > Here is a rather unusual scenario taken from a real life situation. See if you can wade through the conflicting history and S & S as well as the paramedic involved did. > > > > Good luck, > > Donn > > > > ------------------------------------- > > > > A paramedic is working as an assistant to the physician at a rural clinic. Her job is to triage patients, perform initial exams, and route the patient either to the PA, the physicians, or recommend transfer to a facility with better resources. > > > > A 62 YO female patient presents to the clinic. She is ambulatory but moves with some difficulty, assisted by her daughter. Her chief complaint is back and neck pain. Upon questioning she reveals that she started feeling fever and flu-like body aches three days ago, but has developed no upper respiratory symptoms consistent with influenza. She advises that the aches have gotten progressively worse and that now her back and neck cramp " pretty regular " . She has had difficulty rising from a sitting position and can find no position of real comfort. Today her throat started " acting up " and was unable to eat her soup. > > > > The patient appears unkempt and is wearing wrinkled, soiled clothing. As she speaks she is sitting erect on the exam table arching her back, using one hand to rub her neck. The paramedic notices the patient's face is twitching occasionally on the left side and that she is turning her head slightly to that side with each spasm. The paramedic also notices a small, partially healed, undressed wound on the anterior surface of her left wrist. The patient advises that she burned herself while frying bacon " about ten days or two weeks ago " , but that it doesn't hurt anymore. When asked about medical history she states that she had a recent bout with vomiting and for which a physician at another clinic administered " a shot in my butt " and prescribed metronidazole and Donnagel PG. A telephone call to the other clinic verifies the patient was treated and released for gastroenteritis of unknown etiology and the injection to be promethazine HCL. The patient claims that the problem resolved " a few days ago " and she hasn't thrown up since. Other medical history includes hypertension, asthma and multiple minor wounds and fractures resulting from a hard life on a farm. > > > > Among her other medications are aldactone, Zyloprim, lasix, and a half-empty bottle of metronidazole. She states that the " other " doctor has had her on " all sorts of dope " from time to time and that most of it " makes me sick " . Her daughter states that she has half-empty pill bottles all over the house and that she does not take her medications according to doctor's orders. The patient claims that she is allergic to aspirin and penicillin and all " them cains " . The daughter states that her mother has not eaten since yesterday, taking only a few sips of fluid today. She has not been able to take her medications today due to an inability to swallow. She smokes " a pack or so " of unfiltered cigarettes daily " when I can afford 'em " , and she drinks only a little of the wine that she makes herself. Her daughter tells you that her alcohol consumption is greater than the patient admits, and that her mother's homemade wine " scares " her. > > > > Examination reveals an irregular pulse of 104, blood pressure of 152/102, respirations non-labored at 20, oral temperature of 101.9, and pulse-ox reading of 96. Her lung sounds reveal minor wheezing in the upper quadrants bilaterally. Ears, nares, mouth and oral pharynx are unremarkable. Because of the irregular pulse the physician orders a 12-lead, which shows irregular tachycardia, QRS width of 0.15 sec., rSR complex in V1, wide S wave in leads I, aVL, V5 and V6. Head to toe exam reveals that she is indeed trismic and all extremity joints are painful to palpation. Her feet and ankles are very slightly edematous. Palpation of her back elicits frank spasms and pain. She claims that she didn't feel bad enough to see the doctor when her daughter insisted she come, but that " Now that you have been poking on me " , she feels worse and claims to " hurt all over " . > > > > > > Does this patient need referral to another facility, or can we treat her successfully here? > > What potential etiologies must you sort through to make diagnoses? > > What did the 12-lead findings indicate? > > Were the 12-lead findings pertinant to the chief complaint? > > What is the most relevant finding from the history and physical? > > What disease process is most likely the cause of the chief complaint. > > What initial therapy would you recommend? > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 4, 2001 Report Share Posted December 4, 2001 Howdy folks, Regarding our little unusual scenario, I appreciate those who made a stab at it, and I was pleased to see so many arrive at the correct answer - tetanus. Gene Gandy emailed privately and I'll copy his excellent evaluation and recommendations below. He was pretty much dead on, and covered it very well. The one question I purposly left out was tetanus immunization. Congratulations to those that caught that ommission. This woman had never had a dT, so the etiology of her chief complaint was indeed tetanus, with the burn being the most likely route of entry. But this was recent onset and not the reason the first physician prescribed metronidazole. His diagnoses was amoeobic gastroenteritis, for which metronidazole is an appropriate antibiotic. He may have missed the diagnosis, or he may have been correct and the tetanus came later, but if the patient had followed doctor's orders we may have gotten lucky. However, true to her nature, this dear lady started to feel a little better and ceased taking her medication. In any event, later tests showed no evidence of amoeobisis. The burn was the most important finding from the paramedic's initial examination, with the neuromuscular symptoms strongly suggestive of this particular disease process. Although not necessarily pertinant to the tetanus diagnoses the EKG was indicative of RBBB which, as Gene pointed out, was possibly precipitated by the progressing infection. However, it may also have just been the progression of ongoing cardiac disease. Her physician has been treating her COPD for several years and she was recently diagnosed with CHF. A fact that she failed to tell our paramedic evan after specific questioning. The clinic doctor started IV doxycycline before our patient was ambulanced to the big hospital where another 12-lead was ordered by the ED doctor, and full blood labs and cultures were drawn. After evaluation by a virologist, neurologist and cardiologist and the diagnoses was confirmed, tetanus immune globulin was administered IM, IV doxycycline continued, and the burn debrided. She was transferred to the unit where her symptoms stabilized and she was moved to the floor the next day. It was never necessary to intubate as the spasms subsided in only a matter of hours. She made a rather rapid recovery without much further complication and was discharged after only twelve days. It seems that she is a rather tough old bird, and quite lucky, but with such a lifestyle I expect our frontier medic may not have seen the last of this patient. As Mr. said in a previous email, a scenario like this will make you think instead of just react. Now, can anybody explain why paramedics should be interested in a case such as this? Thanks to all who participated, Donn Unusual Scenario > > > > Here is a rather unusual scenario taken from a real life situation. See if > you can wade through the conflicting history and S & S as well as the > paramedic involved did. > > > > > > > > Good luck, > > > > Donn > > > > > > > > ------------------------------------- > > > > > > > > A paramedic is working as an assistant to the physician at a rural clinic. > Her job is to triage patients, perform initial exams, and route the patient > either to the PA, the physicians, or recommend transfer to a facility with > better resources. > > > > > > > > A 62 YO female patient presents to the clinic. She is ambulatory but moves > with some difficulty, assisted by her daughter. Her chief complaint is back > and neck pain. Upon questioning she reveals that she started feeling fever > and flu-like body aches three days ago, but has developed no upper > respiratory symptoms consistent with influenza. She advises that the aches > have gotten progressively worse and that now her back and neck cramp " pretty > regular " . She has had difficulty rising from a sitting position and can find > no position of real comfort. Today her throat started " acting up " and was > unable to eat her soup. > > > > > > > > The patient appears unkempt and is wearing wrinkled, soiled clothing. As > she speaks she is sitting erect on the exam table arching her back, using > one hand to rub her neck. The paramedic notices the patient's face is > twitching occasionally on the left side and that she is turning her head > slightly to that side with each spasm. The paramedic also notices a small, > partially healed, undressed wound on the anterior surface of her left wrist. > The patient advises that she burned herself while frying bacon " about ten > days or two weeks ago " , but that it doesn't hurt anymore. When asked about > medical history she states that she had a recent bout with vomiting and for > which a physician at another clinic administered " a shot in my butt " and > prescribed metronidazole and Donnagel PG. A telephone call to the other > clinic verifies the patient was treated and released for gastroenteritis of > unknown etiology and the injection to be promethazine HCL. The patient > claims that the problem resolved " a few days ago " and she hasn't thrown up > since. Other medical history includes hypertension, asthma and multiple > minor wounds and fractures resulting from a hard life on a farm. > > > > > > > > Among her other medications are aldactone, Zyloprim, lasix, and a > half-empty bottle of metronidazole. She states that the " other " doctor has > had her on " all sorts of dope " from time to time and that most of it " makes > me sick " . Her daughter states that she has half-empty pill bottles all over > the house and that she does not take her medications according to doctor's > orders. The patient claims that she is allergic to aspirin and penicillin > and all " them cains " . The daughter states that her mother has not eaten > since yesterday, taking only a few sips of fluid today. She has not been > able to take her medications today due to an inability to swallow. She > smokes " a pack or so " of unfiltered cigarettes daily " when I can afford > 'em " , and she drinks only a little of the wine that she makes herself. Her > daughter tells you that her alcohol consumption is greater than the patient > admits, and that her mother's homemade wine " scares " her. > > > > > > > > Examination reveals an irregular pulse of 104, blood pressure of 152/102, > respirations non-labored at 20, oral temperature of 101.9, and pulse-ox > reading of 96. Her lung sounds reveal minor wheezing in the upper quadrants > bilaterally. Ears, nares, mouth and oral pharynx are unremarkable. Because > of the irregular pulse the physician orders a 12-lead, which shows irregular > tachycardia, QRS width of 0.15 sec., rSR complex in V1, wide S wave in leads > I, aVL, V5 and V6. Head to toe exam reveals that she is indeed trismic and > all extremity joints are painful to palpation. Her feet and ankles are very > slightly edematous. Palpation of her back elicits frank spasms and pain. She > claims that she didn't feel bad enough to see the doctor when her daughter > insisted she come, but that " Now that you have been poking on me " , she feels > worse and claims to " hurt all over " . > > > > > > > > > > > > Does this patient need referral to another facility, or can we treat her > successfully here? > > > > What potential etiologies must you sort through to make diagnoses? > > > > What did the 12-lead findings indicate? > > > > Were the 12-lead findings pertinant to the chief complaint? > > > > What is the most relevant finding from the history and physical? > > > > What disease process is most likely the cause of the chief complaint. > > > > What initial therapy would you recommend? > > > > > > > > Quote Link to comment Share on other sites More sharing options...
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