Guest guest Posted March 19, 2007 Report Share Posted March 19, 2007 Time for a little puzzler. You are called to an apartment complex where you are met by a security officer and the manager. They advise you that the occupant of #2312 had not been seen in two days and did not answer his door even though his car is parked in its usual place in front. They advise that they opened the apartment door and found him in bed and that they could not arouse him. Upon entering the house you note the a rather sweet, urine-like smell. You ask the manager if she knows whether or not the patient has any medical problems and she answers that she thinks he is diabetic. You find a 36 year old male who appears to be around 6 feet tall and weighing about 150 pounds lying in bed. He has deep, sighing respirations, and does not respond to either voice or to touching his face and eyelashes. His skin is warm and dry, and he appears to be dehydrated. Vital signs are: Pulse 110, BP 90/60, R 20, BGL >500, temp 99.1, O2Sat = 93% on room air, ECG = sinus tach, Capnography = CO2 56. PE reveals a normocephalic male lying supine in bed, breathing at a rate of 20/min, with " sighing " respirations. Inspection of the chest reveals a small amount of chest rise even though the patient appears to be breathing deeply. Auscultation reveals clear and equal but " short " breath sounds bilaterally. S1 and S2 are heard without clicks, splits, thrills or murmurs. Pupils are equal at 5 mm and react to light normally; however, marked redness is noted in the right eye, with what appears to be pus (hypopyon) at the bottom of the anterior chamber. There is no discharge from the eye. Upper and lower extremities appear to have some arthritic changes. There is insulin in the refrigerator but you find no syringes. There is a prescription bottle of indomethacin 50 mg tabs with directions to take 1 tab t.i.d. on the nightstand. You also find a prescription bottle with Atacand 4 to be taken 1 tab ad, and a bottle of Cymbalta 30 mg caps to be taken 1 cap qd. You start two IVs with NS and begin to run fluids. While moving the patient to the stretcher you note that his back seems rigid. You decide to intubate to protect his airway and improve ventilation, but find that his neck is also quite rigid and semi-flexed. His mouth is difficult to open as well. You place a pillow under his head and once again attempt to extend his neck but his neck is rigid and you cannot achieve a view of the cords. You also note that the head resists gentle efforts at rotation. You determine to forego intubation, insert a couple of nasopharyngeal airways and place him on a non-rebreather at 15 lpm and transport. What is the probable reason for his spinal and nuchal rigidity? GG ************************************** AOL now offers free email to everyone. Find out more about what's free from AOL at http://www.aol.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 19, 2007 Report Share Posted March 19, 2007 Gene, I am sure there another name for it, I remember it being called Stiff-person syndrome. Ron ************************************** AOL now offers free email to everyone. Find out more about what's free from AOL at http://www.aol.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 19, 2007 Report Share Posted March 19, 2007 Sorry! It's not an infectious process. G > > Meningitis would explain the stiff neck and spine. > > Jeff > > ************************************** AOL now offers free email to everyone. Find out more about what's free from AOL at http://www.aol.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 19, 2007 Report Share Posted March 19, 2007 I think you're on the trail! GG > > > > > Gene, > > I am sure there another name for it, I remember it being called > Stiff-person syndrome. > > Ron > > > ************ ******** ******** ************<wbr>*********<wbr>*********<wbr> > ** > Find out more about what's free from AOL at http://www.aol.http > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 19, 2007 Report Share Posted March 19, 2007 Meningitis would explain the stiff neck and spine. Jeff Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 19, 2007 Report Share Posted March 19, 2007 Could it be a cymbalta overdose which is a selective serotonin and norepinephrine reuptake inhibitors or could it be Neuroleptic malignant syndrome Hobbs wegandy1938@... wrote: Time for a little puzzler. You are called to an apartment complex where you are met by a security officer and the manager. They advise you that the occupant of #2312 had not been seen in two days and did not answer his door even though his car is parked in its usual place in front. They advise that they opened the apartment door and found him in bed and that they could not arouse him. Upon entering the house you note the a rather sweet, urine-like smell. You ask the manager if she knows whether or not the patient has any medical problems and she answers that she thinks he is diabetic. You find a 36 year old male who appears to be around 6 feet tall and weighing about 150 pounds lying in bed. He has deep, sighing respirations, and does not respond to either voice or to touching his face and eyelashes. His skin is warm and dry, and he appears to be dehydrated. Vital signs are: Pulse 110, BP 90/60, R 20, BGL >500, temp 99.1, O2Sat = 93% on room air, ECG = sinus tach, Capnography = CO2 56. PE reveals a normocephalic male lying supine in bed, breathing at a rate of 20/min, with " sighing " respirations. Inspection of the chest reveals a small amount of chest rise even though the patient appears to be breathing deeply. Auscultation reveals clear and equal but " short " breath sounds bilaterally. S1 and S2 are heard without clicks, splits, thrills or murmurs. Pupils are equal at 5 mm and react to light normally; however, marked redness is noted in the right eye, with what appears to be pus (hypopyon) at the bottom of the anterior chamber. There is no discharge from the eye. Upper and lower extremities appear to have some arthritic changes. There is insulin in the refrigerator but you find no syringes. There is a prescription bottle of indomethacin 50 mg tabs with directions to take 1 tab t.i.d. on the nightstand. You also find a prescription bottle with Atacand 4 to be taken 1 tab ad, and a bottle of Cymbalta 30 mg caps to be taken 1 cap qd. You start two IVs with NS and begin to run fluids. While moving the patient to the stretcher you note that his back seems rigid. You decide to intubate to protect his airway and improve ventilation, but find that his neck is also quite rigid and semi-flexed. His mouth is difficult to open as well. You place a pillow under his head and once again attempt to extend his neck but his neck is rigid and you cannot achieve a view of the cords. You also note that the head resists gentle efforts at rotation. You determine to forego intubation, insert a couple of nasopharyngeal airways and place him on a non-rebreather at 15 lpm and transport. What is the probable reason for his spinal and nuchal rigidity? GG ************************************** AOL now offers free email to everyone. Find out more about what's free from AOL at http://www.aol.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 19, 2007 Report Share Posted March 19, 2007 In a message dated 3/19/2007 7:25:50 PM Central Daylight Time, wegandy1938@... writes: There is insulin in the refrigerator but you find no syringes. There is a prescription bottle of indomethacin 50 mg tabs with directions to take 1 tab t.i.d. on the nightstand. You also find a prescription bottle with Atacand 4 to be taken 1 tab ad, and a bottle of Cymbalta 30 mg caps to be taken 1 cap qd. I'm waiting to see if someone asks about a rare but potentially fatal drug interaction with this chap's medications... ck S. Krin, DO FAAFP ************************************** AOL now offers free email to everyone. Find out more about what's free from AOL at http://www.aol.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 20, 2007 Report Share Posted March 20, 2007 In a message dated 3/20/2007 8:02:01 AM Central Daylight Time, teenascorner@... writes: Would it be Ankylosing Spondylitis? Nope...that is a rheumatoid type disease that probably will not have any bearing on either Gene's original question or mine... ck S. Krin, DO FAAFP ************************************** AOL now offers free email to everyone. Find out more about what's free from AOL at http://www.aol.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 20, 2007 Report Share Posted March 20, 2007 Would it be Ankylosing Spondylitis? > > > In a message dated 3/19/2007 7:25:50 PM Central Daylight Time, > wegandy1938@... writes: > > There is insulin in the refrigerator but you find no syringes. There is a > prescription bottle of indomethacin 50 mg tabs with directions to take 1 tab > t.i.d. on the nightstand. You also find a prescription bottle with Atacand > 4 to be taken 1 tab ad, and a bottle of Cymbalta 30 mg caps to be taken 1 > cap > qd. > > > > I'm waiting to see if someone asks about a rare but potentially fatal drug > interaction with this chap's medications... > > ck > S. Krin, DO FAAFP > > > > ************************************** AOL now offers free email to everyone. > Find out more about what's free from AOL at http://www.aol.com. > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 20, 2007 Report Share Posted March 20, 2007 Gene, Do we know what this man does for a living? Has he suffered any recent injuries, minor or otherwise? Is the patient up on all of his vaccinations, mainly tetanus? After checking all of his medications, indomethacin and Atacand could have a potential to cause renal issue, including toxicity and could affect the htn medication. These two medications can have an antagonist, additive effect. I am leaning toward Tetanus or " lock jaw " . Bernie Stafford LPN EMTP ________________________________________ From: texasems-l [mailto:texasems-l ] On Behalf Of wegandy1938@... Sent: Monday, March 19, 2007 7:22 PM To: texasems-l ; paramedicine (AT) e; WEGandy@... Subject: A puzzler Time for a little puzzler. You are called to an apartment complex where you are met by a security officer and the manager. They advise you that the occupant of #2312 had not been seen in two days and did not answer his door even though his car is parked in its usual place in front. They advise that they opened the apartment door and found him in bed and that they could not arouse him. Upon entering the house you note the a rather sweet, urine-like smell. You ask the manager if she knows whether or not the patient has any medical problems and she answers that she thinks he is diabetic. You find a 36 year old male who appears to be around 6 feet tall and weighing about 150 pounds lying in bed. He has deep, sighing respirations, and does not respond to either voice or to touching his face and eyelashes. His skin is warm and dry, and he appears to be dehydrated. Vital signs are: Pulse 110, BP 90/60, R 20, BGL >500, temp 99.1, O2Sat = 93% on room air, ECG = sinus tach, Capnography = CO2 56. PE reveals a normocephalic male lying supine in bed, breathing at a rate of 20/min, with " sighing " respirations. Inspection of the chest reveals a small amount of chest rise even though the patient appears to be breathing deeply. Auscultation reveals clear and equal but " short " breath sounds bilaterally. S1 and S2 are heard without clicks, splits, thrills or murmurs. Pupils are equal at 5 mm and react to light normally; however, marked redness is noted in the right eye, with what appears to be pus (hypopyon) at the bottom of the anterior chamber. There is no discharge from the eye. Upper and lower extremities appear to have some arthritic changes. There is insulin in the refrigerator but you find no syringes. There is a prescription bottle of indomethacin 50 mg tabs with directions to take 1 tab t.i.d. on the nightstand. You also find a prescription bottle with Atacand 4 to be taken 1 tab ad, and a bottle of Cymbalta 30 mg caps to be taken 1 cap qd. You start two IVs with NS and begin to run fluids. While moving the patient to the stretcher you note that his back seems rigid. You decide to intubate to protect his airway and improve ventilation, but find that his neck is also quite rigid and semi-flexed. His mouth is difficult to open as well. You place a pillow under his head and once again attempt to extend his neck but his neck is rigid and you cannot achieve a view of the cords. You also note that the head resists gentle efforts at rotation. You determine to forego intubation, insert a couple of nasopharyngeal airways and place him on a non-rebreather at 15 lpm and transport. What is the probable reason for his spinal and nuchal rigidity? GG ************************************** AOL now offers free email to everyone. Find out more about what's free from AOL at http://www.aol.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 20, 2007 Report Share Posted March 20, 2007 In a message dated 3/20/2007 4:51:45 PM Central Daylight Time, jeffmedic@... writes: Rheumatoid arthritis would explain the stiff neck and back plus why he is taking indomethacin. Anemia would explain the mild hypoxia. I assume that the DKA would make things worse. I'm also guessing that he takes the Cymbalta for neuropathy. I still haven't figured out the drug interaction yet. RA probably would not have made the neck that stiff-remember that RA itself is more a peripheral disease and would have noticeable changes of the distal joints, in particular the fingers, wrists or knees-long before the disease progressed to a stiff neck of this magnitude. In addition, it would be almost criminally negligent to have someone *only* on indomethacin for RA when we have some very good, fairly safe, disease modifying agents out there. Hint: Why do we recommend that diabetics take either Angiotensin Converting Enzyme inhibitors or Angiotensin Release Blockers? ck S. Krin, DO FAAFP ************************************** AOL now offers free email to everyone. Find out more about what's free from AOL at http://www.aol.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 20, 2007 Report Share Posted March 20, 2007 Rheumatoid arthritis would explain the stiff neck and back plus why he is taking indomethacin. Anemia would explain the mild hypoxia. I assume that the DKA would make things worse. I'm also guessing that he takes the Cymbalta for neuropathy. I still haven't figured out the drug interaction yet. Jeff Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 20, 2007 Report Share Posted March 20, 2007 In a message dated 3/20/2007 12:30:31 PM Central Daylight Time, staffdoc@... writes: After checking all of his medications, indomethacin and Atacand could have a potential to cause renal issue, including toxicity and could affect the htn medication. These two medications can have an antagonist, additive effect. I am leaning toward Tetanus or " lock jaw " . OK...give Bernie a jujube for catching on to the idea of acute renal failure due to the interaction of an Angiotension blocker/ACEi and a Nonsteroidal... It's a subtle point, and one that we don't see as much now as we did when Captopril first came out, but it's pretty dramatic when it does come out....fortunately, also survivable with a modicum of good support, as it will often be reversible with time. It also accounts for the odor noted when the team first entered the room (that sweet 'uremic' smell is characteristic for acute renal failure). What finding is NOT indicative of this being tetanus? ck S. Krin, DO FAAFP ************************************** AOL now offers free email to everyone. Find out more about what's free from AOL at http://www.aol.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 20, 2007 Report Share Posted March 20, 2007 My first thought is meningitis due to the pus found in the eye, a sure sign of an infection, even if there is no drainage. What is the skin condition, cool and moist or hot and dry. We cannot rule out the possibility of diabetic ketoacidosis either since the BGL is >500mg/dl. I thought about the possibility of drug interactions and found none when I checked the 2005 electronic PDR. The only thing I would change besides airway support, bilateral IVs and monitoring is a mask to protect myself and my partner. Am I close or way off base? Interesting case. Let me know. Anita NREMTP/LP Take care and stay safe always. " Commit to the Lord whatever you do, and your plans will succeed. " (Proverbs: 16:3) May God Smile on you today. --------------------------------- Don't be flakey. Get Yahoo! Mail for Mobile and always stay connected to friends. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 20, 2007 Report Share Posted March 20, 2007 WE HAVE A WINNER!!! Yes, it is AS. Congratulatons. You win a two week trip to Ladonia, TX, to stay in the Ladonia Inn, a 19th Century barn converted to a B and B. It has all the things that travelers 100 years ago would expect--a bed of straw, an outhouse, and boiled potatoes for breakfast. ENJOY! GG > > Would it be Ankylosing Spondylitis? > > > > > > > > In a message dated 3/19/2007 7:25:50 PM Central Daylight Time, > > wegandy1938@ wegandy193 > > > > There is insulin in the refrigerator but you find no syringes. > There is a > > prescription bottle of indomethacin 50 mg tabs with directions to > take 1 tab > > t.i.d. on the nightstand. You also find a prescription bottle with > Atacand > > 4 to be taken 1 tab ad, and a bottle of Cymbalta 30 mg caps to be > taken 1 > > cap > > qd. > > > > > > > > I'm waiting to see if someone asks about a rare but potentially > fatal drug > > interaction with this chap's medications. i > > > > ck > > S. Krin, DO FAAFP > > > > > > > > ************ ******** ******** ************<wbr>*********<wbr>****** > everyone. > > Find out more about what's free from AOL at http://www.aol.http > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 20, 2007 Report Share Posted March 20, 2007 This guy has had a long history of this condition. It started when he was about 19 years old. Gene ************************************** AOL now offers free email to everyone. Find out more about what's free from AOL at http://www.aol.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 20, 2007 Report Share Posted March 20, 2007 Bernie, Good guess but not the answer. Look for an underlying condition unrelated to drugs. GG > > Gene, > > Do we know what this man does for a living? Has he suffered any recent > injuries, minor or otherwise? Is the patient up on all of his vaccinations, > mainly tetanus? > > After checking all of his medications, indomethacin and Atacand could have a > potential to cause renal issue, including toxicity and could affect the htn > medication. These two medications can have an antagonist, additive effect. > > I am leaning toward Tetanus or " lock jaw " . > > Bernie Stafford LPN EMTP > ____________ ________ ________ ________ > From: texasems-l@yahoogrotexasem [mailto:texasems-l@yahoogrotexasem] On > Behalf Of wegandy1938@wegandy > Sent: Monday, March 19, 2007 7:22 PM > To: texasems-l@yahoogrotexasem; paramedicine@paramedicin; WEGandy@... > Subject: A puzzler > > Time for a little puzzler. > > You are called to an apartment complex where you are met by a security > officer and the manager. They advise you that the occupant of #2312 had not > been > seen in two days and did not answer his door even though his car is parked > in > its usual place in front. > > They advise that they opened the apartment door and found him in bed and > that > they could not arouse him. > > Upon entering the house you note the a rather sweet, urine-like smell. You > ask the manager if she knows whether or not the patient has any medical > problems and she answers that she thinks he is diabetic. > > You find a 36 year old male who appears to be around 6 feet tall and > weighing > about 150 pounds lying in bed. He has deep, sighing respirations, and does > not respond to either voice or to touching his face and eyelashes. His skin > is warm and dry, and he appears to be dehydrated. > > Vital signs are: Pulse 110, BP 90/60, R 20, BGL >500, temp 99.1, O2Sat = > 93% on room air, ECG = sinus tach, Capnography = CO2 56. > > PE reveals a normocephalic male lying supine in bed, breathing at a rate of > 20/min, with " sighing " respirations. Inspection of the chest reveals a small > > amount of chest rise even though the patient appears to be breathing deeply. > > Auscultation reveals clear and equal but " short " breath sounds bilaterally. > S1 and S2 are heard without clicks, splits, thrills or murmurs. Pupils are > equal at 5 mm and react to light normally; however, marked redness is noted > in > the right eye, with what appears to be pus (hypopyon) at the bottom of the > anterior chamber. There is no discharge from the eye. > > Upper and lower extremities appear to have some arthritic changes. > > There is insulin in the refrigerator but you find no syringes. There is a > prescription bottle of indomethacin 50 mg tabs with directions to take 1 tab > > t.i.d. on the nightstand. You also find a prescription bottle with Atacand > 4 to be taken 1 tab ad, and a bottle of Cymbalta 30 mg caps to be taken 1 > cap > qd. > > You start two IVs with NS and begin to run fluids. While moving the patient > to the stretcher you note that his back seems rigid. You decide to intubate > to protect his airway and improve ventilation, but find that his neck is > also > quite rigid and semi-flexed. His mouth is difficult to open as well. You > place a pillow under his head and once again attempt to extend his neck but > his > neck is rigid and you cannot achieve a view of the cords. You also note > that the head resists gentle efforts at rotation. You determine to forego > intubation, insert a couple of nasopharyngeal airways and place him on a > non-rebreather at 15 lpm and transport. > > What is the probable reason for his spinal and nuchal rigidity? > > GG > > ************ ******** ******** ******* > AOL now offers free email to > everyone. Find out more about what's free from AOL at http://www.aol.http > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 20, 2007 Report Share Posted March 20, 2007 You're doing some great critical thinking. You're not there yet, but you're on the trail. GG > > Rheumatoid arthritis would explain the stiff neck and back plus why he is > taking indomethacin. Anemia would explain the mild hypoxia. I assume that > the DKA would make things worse. I'm also guessing that he takes the > Cymbalta for neuropathy. I still haven't figured out the drug interaction > yet. > > Jeff > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 21, 2007 Report Share Posted March 21, 2007 -Yes, AS is an autoimmune disease that falls under the Rheumatoid Arthritis catagories. However, it primarily strikes young men by the time they are 20 and is aggressive. The process of this disease is that it will fuse the joints of the spine (stiff neck), shoulders, hips, and ribs (shallow breathing). In fact many of them will die from the decreasing ability to breath properly and associated complications of such. Considering this mans age, it is easy to conclude that he is probably in the advanced stages of this disease. Guess I DID pay attention and learn something in college all those years ago after all, hehe. Teena Welch, AAS, EMT-B -- In texasems-l , krin135@... wrote: > > > In a message dated 3/20/2007 8:02:01 AM Central Daylight Time, > teenascorner@... writes: > > Would it be Ankylosing Spondylitis? > > > Nope...that is a rheumatoid type disease that probably will not have any > bearing on either Gene's original question or mine... > > ck > S. Krin, DO FAAFP > > > > ************************************** AOL now offers free email to everyone. > Find out more about what's free from AOL at http://www.aol.com. > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 21, 2007 Report Share Posted March 21, 2007 Yes he does have ketoacidosis, and his skin is warm and dry. But that's not the problem with his neck. It's not a drug interaction either. GG > > My first thought is meningitis due to the pus found in the eye, a sure sign > of an infection, even if there is no drainage. What is the skin condition, > cool and moist or hot and dry. We cannot rule out the possibility of diabetic > ketoacidosis either since the BGL is >500mg/dl. I thought about the > possibility of drug interactions and found none when I checked the 2005 electronic PDR. > The only thing I would change besides airway support, bilateral IVs and > monitoring is a mask to protect myself and my partner. Am I close or way off > base? Interesting case. Let me know. > Anita > NREMTP/LP > > Take care and stay safe always. > " Commit to the Lord whatever you do, and your plans will succeed. " > (Proverbs: 16:3) > May God Smile on you today. > > > > ------------ -------- -------- -- > Don't be flakey. Get Yahoo! Mail for Mobile and > always stay connected to friends. > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 21, 2007 Report Share Posted March 21, 2007 Congratulations to Tina Welch and Bob Breese, who got the right answer, ankylosing spondylitis, almost simultaneously. The other conditions and hints were just red herrings. AS patients can be very hard to intubate. It is impossible to hyperextend their necks when they have advanced disease, and attempts to do so can result in spinal fractures. The spine takes on a typical appearance in xrays that is called " bamboo spine. " The vertebrae are fused together, and the picture looks like a stalk of bamboo. Thanks to all who gave such thoughtful answers. Gene G. > > -Yes, AS is an autoimmune disease that falls under the Rheumatoid > Arthritis catagories. However, it primarily strikes young men by the > time they are 20 and is aggressive. The process of this disease is > that it will fuse the joints of the spine (stiff neck), shoulders, > hips, and ribs (shallow breathing). In fact many of them will die > from the decreasing ability to breath properly and associated > complications of such. Considering this mans age, it is easy to > conclude that he is probably in the advanced stages of this disease. > > Guess I DID pay attention and learn something in college all those > years ago after all, hehe. > > Teena Welch, AAS, EMT-B > > -- In texasems-l@yahoogrotexasem, krin135@... wrote: > > > > > > In a message dated 3/20/2007 8:02:01 AM Central Daylight Time, > > teenascorner@ teenascorn > > > > Would it be Ankylosing Spondylitis? > > > > > > Nope...that is a rheumatoid type disease that probably will not > have any > > bearing on either Gene's original question or mine... > > > > ck > > S. Krin, DO FAAFP > > > > > > > > ************ ******** ******** ************<wbr>*********<wbr>****** > everyone. > > Find out more about what's free from AOL at http://www.aol.http > > > > > > Quote Link to comment Share on other sites More sharing options...
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