A new puzzler for the New Year

[Guest guest]

Hi, boys and girls. Ready for a new mind twister? I knew you were.

You are called to the home of a 70 year old female who complains of general

weakness and hiccups that have lasted for the last two days without relief.

You observe a female patient sitting on the sofa in her living room. She

appears to be around 5'6 " tall and looks to weigh approximately 225 pounds.

She is visibly hiccuping about ever second. She looks to be in mild distress

but is able to talk easily between hiccups.

She tells you that she first got the hiccups yesterday, and in spite of all

the " tricks " she and her friends know, nothing has stopped them. She is " at

my wits end with this. " She further says that when she stands up she gets

dizzy and only feels good when sitting or lying down. She was unable to sleep

much last night because of the hiccups.

Vital signs are:

Pulse irregular and ranging from 40 to 50 with occasional longer pauses.

Respirations about 15 and difficult to count because of the muscle

contractions in the area of the diaphragm when she hiccups.

BP 100/60 lying; 98/60 sitting (left arm)

SaO2 97% on room air

Tympanic temperature 98

Blood glucose 104

As you are placing the leads on her chest to do a 12-lead, you notice that

she has a pacemaker. On questioning, she states that she got the pacemaker

about 7 months ago after experiencing a slow and irregular heartbeat. She says

it has been working fine as far as she knows. She denies chest pain or

discomfort other than the hiccups, denies nausea/vomiting. Bowel and urine

excretion normal.

She states that she takes Atacand for blood pressure, Coumadin as a " blood

thinner, " synthroid for thyroid problem, Xanax for sleep, Zoloft for mild

depression, and Metanx. She says that she takes her medicine " religiously "

every

day and has missed no doses.

Her 12-lead shows controlled atrial fibrillation without evidence of

pacemaker capture. As you question her further, she reveals that she believes

that

her pacemaker is a " vertical demand. " You interpret that to be a ventricular

demand pacer. A repeat EKG done at double speed again shows no visible

pacemaker spikes.

Physical exam reveals:

LOC oriented to person, place, time, and able to answer questions and relate

events coherently.

Skin: pink, warm and dry with non-erythematous lentigo on backs of hands

and forearms.

HEENT: normocephalic female with false teeth and glasses. Pupils equal at

4 mm and reactive to light; normal movement following pen, no nystagmus.

Tongue and buccal surfaces normal looking, no halitosis. No hearing aid. No

masses or lymphadenopathy felt in neck. Jugular veins non-distended.

Trachea midline.

Chest: bilateral breath sounds without rales, ronchi, or wheezes. Heart

sounds S1 and S2 clearly heard. No pulse deficits. One healed scar at the

site of the pacemaker. Normal looking breasts for age. Rhythmic movements

coinciding with hiccups, approximately every second.

Abdomen: Obese abdomen with rhythmic movement corresponding to hiccups.

Non-tender to palpation, non-distended, no surgical scars. No palpable

masses. Denies diarrhea, stomach pain, cramps.

Lower extremities: Obese with varicose veins and mild pedal edema.

Dorsalis pedis and tibial pulses not palpable but capillary refill 4 seconds.

Upper extremities: Obese with bilateral radial pulses. Capillary refill 3

seconds.

Back: unremarkable

The patient confides that she has been trying to lose some weight by going on

a diet and has recently joined a health club and has started swimming every

day about a month before. She last swam yesterday morning before the

hiccups started. She has been eating and drinking normally. She denies ETOH

use

or recreational drug use.

After thinking things over for a couple of minutes you think you know what's

causing her hiccups. What is it, and what is it called?

Gene Gandy, JD, NREMT-P, LP, Evil Scenario Doctor (ESD)

**************

New

year...new news. Be the first to know what is making headlines.

(http://www.aol.com/?ncid=emlcntaolcom00000026)

[Guest guest]

Not a bad guess, but not the correct cause.

GG

>

> Stab in the dark: pericarditis - the phrenic nerve runs along the

> pericardium and can become inflamed causing hiccups.

>

> This is very much a stab in the dark, 6 hours til end of shift

>

> Joe percer, lp

>

>

> > Hi, boys and girls. Ready for a new mind twister? I knew you were.

> >

> > You are called to the home of a 70 year old female who complains of

> general

> > weakness and hiccups that have lasted for the last two days without

> relief.

> >

> > You observe a female patient sitting on the sofa in her living room. She

> > appears to be around 5'6 " tall and looks to weigh approximately 225

> pounds.

> >

> > She is visibly hiccuping about ever second. She looks to be in mild

> > distress

> > but is able to talk easily between hiccups.

> >

> > She tells you that she first got the hiccups yesterday, and in spite of

> all

> > the " tricks " she and her friends know, nothing has stopped them. She is

> > " at

> > my wits end with this. " She further says that when she stands up she gets

> > dizzy and only feels good when sitting or lying down. She was unable to

> > sleep

> > much last night because of the hiccups.

> >

> > Vital signs are:

> >

> > Pulse irregular and ranging from 40 to 50 with occasional longer pauses.

> > Respirations about 15 and difficult to count because of the muscle

> > contractions in the area of the diaphragm when she hiccups.

> > BP 100/60 lying; 98/60 sitting (left arm)

> > SaO2 97% on room air

> > Tympanic temperature 98

> > Blood glucose 104

> >

> > As you are placing the leads on her chest to do a 12-lead, you notice that

> > she has a pacemaker. On questioning, she states that she got the pacemaker

> > about 7 months ago after experiencing a slow and irregular heartbeat. She

> > says

> > it has been working fine as far as she knows. She denies chest pain or

> > discomfort other than the hiccups, denies nausea/vomiting. Bowel and urine

> > excretion normal.

> >

> > She states that she takes Atacand for blood pressure, Coumadin as a " blood

> > thinner, " synthroid for thyroid problem, Xanax for sleep, Zoloft for mild

> > depression, and Metanx. She says that she takes her medicine " religiously "

> > every

> > day and has missed no doses.

> >

> > Her 12-lead shows controlled atrial fibrillation without evidence of

> > pacemaker capture. As you question her further, she reveals that she

> > believes that

> > her pacemaker is a " vertical demand. " You interpret that to be a

> > ventricular

> > demand pacer. A repeat EKG done at double speed again shows no visible

> > pacemaker spikes.

> >

> > Physical exam reveals:

> >

> > LOC oriented to person, place, time, and able to answer questions and

> relate

> > events coherently.

> > Skin: pink, warm and dry with non-erythematous lentigo on backs of hands

> > and forearms.

> >

> > HEENT: normocephalic female with false teeth and glasses. Pupils equal

> > at

> > 4 mm and reactive to light; normal movement following pen, no nystagmus.

> > Tongue and buccal surfaces normal looking, no halitosis. No hearing aid.

> > No

> > masses or lymphadenopathy felt in neck. Jugular veins non-distended.

> > Trachea midline.

> >

> > Chest: bilateral breath sounds without rales, ronchi, or wheezes. Heart

> > sounds S1 and S2 clearly heard. No pulse deficits. One healed scar at

> > the

> > site of the pacemaker. Normal looking breasts for age. Rhythmic movements

> > coinciding with hiccups, approximately every second.

> >

> > Abdomen: Obese abdomen with rhythmic movement corresponding to hiccups.

> > Non-tender to palpation, non-distended, no surgical scars. No palpable

> > masses. Denies diarrhea, stomach pain, cramps.

> >

> > Lower extremities: Obese with varicose veins and mild pedal edema.

> > Dorsalis pedis and tibial pulses not palpable but capillary refill 4

> > seconds.

> >

> > Upper extremities: Obese with bilateral radial pulses. Capillary refill

> > 3

> > seconds.

> >

> > Back: unremarkable

> >

> > The patient confides that she has been trying to lose some weight by going

> > on

> > a diet and has recently joined a health club and has started swimming

> every

> > day about a month before. She last swam yesterday morning before the

> > hiccups started. She has been eating and drinking normally. She denies

> > ETOH use

> > or recreational drug use.

> >

> > After thinking things over for a couple of minutes you think you know

> what's

> > causing her hiccups. What is it, and what is it called?

> >

> > Gene Gandy, JD, NREMT-P, LP, Evil Scenario Doctor (ESD)

> >

> >

> > ************ *

> > New

> > year...new news. Be the first to know what is making headlines.

> > (http://www.aol.http://wwwhttp://www.aol.http)

> >

> >

> >

[Guest guest]

Stab in the dark: pericarditis - the phrenic nerve runs along the

pericardium and can become inflamed causing hiccups.

This is very much a stab in the dark, 6 hours til end of shift

Joe percer, lp

> Hi, boys and girls. Ready for a new mind twister? I knew you were.

>

> You are called to the home of a 70 year old female who complains of general

> weakness and hiccups that have lasted for the last two days without relief.

>

> You observe a female patient sitting on the sofa in her living room. She

> appears to be around 5'6 " tall and looks to weigh approximately 225 pounds.

>

> She is visibly hiccuping about ever second. She looks to be in mild

> distress

> but is able to talk easily between hiccups.

>

> She tells you that she first got the hiccups yesterday, and in spite of all

> the " tricks " she and her friends know, nothing has stopped them. She is

> " at

> my wits end with this. " She further says that when she stands up she gets

> dizzy and only feels good when sitting or lying down. She was unable to

> sleep

> much last night because of the hiccups.

>

> Vital signs are:

>

> Pulse irregular and ranging from 40 to 50 with occasional longer pauses.

> Respirations about 15 and difficult to count because of the muscle

> contractions in the area of the diaphragm when she hiccups.

> BP 100/60 lying; 98/60 sitting (left arm)

> SaO2 97% on room air

> Tympanic temperature 98

> Blood glucose 104

>

> As you are placing the leads on her chest to do a 12-lead, you notice that

> she has a pacemaker. On questioning, she states that she got the pacemaker

> about 7 months ago after experiencing a slow and irregular heartbeat. She

> says

> it has been working fine as far as she knows. She denies chest pain or

> discomfort other than the hiccups, denies nausea/vomiting. Bowel and urine

> excretion normal.

>

> She states that she takes Atacand for blood pressure, Coumadin as a " blood

> thinner, " synthroid for thyroid problem, Xanax for sleep, Zoloft for mild

> depression, and Metanx. She says that she takes her medicine " religiously "

> every

> day and has missed no doses.

>

> Her 12-lead shows controlled atrial fibrillation without evidence of

> pacemaker capture. As you question her further, she reveals that she

> believes that

> her pacemaker is a " vertical demand. " You interpret that to be a

> ventricular

> demand pacer. A repeat EKG done at double speed again shows no visible

> pacemaker spikes.

>

> Physical exam reveals:

>

> LOC oriented to person, place, time, and able to answer questions and relate

> events coherently.

> Skin: pink, warm and dry with non-erythematous lentigo on backs of hands

> and forearms.

>

> HEENT: normocephalic female with false teeth and glasses. Pupils equal

> at

> 4 mm and reactive to light; normal movement following pen, no nystagmus.

> Tongue and buccal surfaces normal looking, no halitosis. No hearing aid.

> No

> masses or lymphadenopathy felt in neck. Jugular veins non-distended.

> Trachea midline.

>

> Chest: bilateral breath sounds without rales, ronchi, or wheezes. Heart

> sounds S1 and S2 clearly heard. No pulse deficits. One healed scar at

> the

> site of the pacemaker. Normal looking breasts for age. Rhythmic movements

> coinciding with hiccups, approximately every second.

>

> Abdomen: Obese abdomen with rhythmic movement corresponding to hiccups.

> Non-tender to palpation, non-distended, no surgical scars. No palpable

> masses. Denies diarrhea, stomach pain, cramps.

>

> Lower extremities: Obese with varicose veins and mild pedal edema.

> Dorsalis pedis and tibial pulses not palpable but capillary refill 4

> seconds.

>

> Upper extremities: Obese with bilateral radial pulses. Capillary refill

> 3

> seconds.

>

> Back: unremarkable

>

> The patient confides that she has been trying to lose some weight by going

> on

> a diet and has recently joined a health club and has started swimming every

> day about a month before. She last swam yesterday morning before the

> hiccups started. She has been eating and drinking normally. She denies

> ETOH use

> or recreational drug use.

>

> After thinking things over for a couple of minutes you think you know what's

> causing her hiccups. What is it, and what is it called?

>

> Gene Gandy, JD, NREMT-P, LP, Evil Scenario Doctor (ESD)

>

>

> **************

> New

> year...new news. Be the first to know what is making headlines.

> (http://www.aol.com/?ncid=emlcntaolcom00000026)

>

>

>

[Guest guest]

Broken pacemaker wire causing the diaphragm to spasm.

Randy E. RN, LP

[Guest guest]

Pace maker slipped and is resting near diaphram and is causing it to spasm

Henry

Re: A new puzzler for the New Year

Not a bad guess, but not the correct cause.

GG

>

> Stab in the dark: pericarditis - the phrenic nerve runs along the

> pericardium and can become inflamed causing hiccups.

>

> This is very much a stab in the dark, 6 hours til end of shift

>

> Joe percer, lp

>

>

> > Hi, boys and girls. Ready for a new mind twister? I knew you were.

> >

> > You are called to the home of a 70 year old female who complains of

> general

> > weakness and hiccups that have lasted for the last two days without

> relief.

> >

> > You observe a female patient sitting on the sofa in her living room. She

> > appears to be around 5'6 " tall and looks to weigh approximately 225

> pounds.

> >

> > She is visibly hiccuping about ever second. She looks to be in mild

> > distress

> > but is able to talk easily between hiccups.

> >

> > She tells you that she first got the hiccups yesterday, and in spite of

> all

> > the " tricks " she and her friends know, nothing has stopped them. She is

> > " at

> > my wits end with this. " She further says that when she stands up she gets

> > dizzy and only feels good when sitting or lying down. She was unable to

> > sleep

> > much last night because of the hiccups.

> >

> > Vital signs are:

> >

> > Pulse irregular and ranging from 40 to 50 with occasional longer pauses.

> > Respirations about 15 and difficult to count because of the muscle

> > contractions in the area of the diaphragm when she hiccups.

> > BP 100/60 lying; 98/60 sitting (left arm)

> > SaO2 97% on room air

> > Tympanic temperature 98

> > Blood glucose 104

> >

> > As you are placing the leads on her chest to do a 12-lead, you notice that

> > she has a pacemaker. On questioning, she states that she got the pacemaker

> > about 7 months ago after experiencing a slow and irregular heartbeat. She

> > says

> > it has been working fine as far as she knows. She denies chest pain or

> > discomfort other than the hiccups, denies nausea/vomiting. Bowel and urine

> > excretion normal.

> >

> > She states that she takes Atacand for blood pressure, Coumadin as a " blood

> > thinner, " synthroid for thyroid problem, Xanax for sleep, Zoloft for mild

> > depression, and Metanx. She says that she takes her medicine " religiously "

> > every

> > day and has missed no doses.

> >

> > Her 12-lead shows controlled atrial fibrillation without evidence of

> > pacemaker capture. As you question her further, she reveals that she

> > believes that

> > her pacemaker is a " vertical demand. " You interpret that to be a

> > ventricular

> > demand pacer. A repeat EKG done at double speed again shows no visible

> > pacemaker spikes.

> >

> > Physical exam reveals:

> >

> > LOC oriented to person, place, time, and able to answer questions and

> relate

> > events coherently.

> > Skin: pink, warm and dry with non-erythematous lentigo on backs of hands

> > and forearms.

> >

> > HEENT: normocephalic female with false teeth and glasses. Pupils equal

> > at

> > 4 mm and reactive to light; normal movement following pen, no nystagmus.

> > Tongue and buccal surfaces normal looking, no halitosis. No hearing aid.

> > No

> > masses or lymphadenopathy felt in neck. Jugular veins non-distended.

> > Trachea midline.

> >

> > Chest: bilateral breath sounds without rales, ronchi, or wheezes. Heart

> > sounds S1 and S2 clearly heard. No pulse deficits. One healed scar at

> > the

> > site of the pacemaker. Normal looking breasts for age. Rhythmic movements

> > coinciding with hiccups, approximately every second.

> >

> > Abdomen: Obese abdomen with rhythmic movement corresponding to hiccups.

> > Non-tender to palpation, non-distended, no surgical scars. No palpable

> > masses. Denies diarrhea, stomach pain, cramps.

> >

> > Lower extremities: Obese with varicose veins and mild pedal edema.

> > Dorsalis pedis and tibial pulses not palpable but capillary refill 4

> > seconds.

> >

> > Upper extremities: Obese with bilateral radial pulses. Capillary refill

> > 3

> > seconds.

> >

> > Back: unremarkable

> >

> > The patient confides that she has been trying to lose some weight by going

> > on

> > a diet and has recently joined a health club and has started swimming

> every

> > day about a month before. She last swam yesterday morning before the

> > hiccups started. She has been eating and drinking normally. She denies

> > ETOH use

> > or recreational drug use.

> >

> > After thinking things over for a couple of minutes you think you know

> what's

> > causing her hiccups. What is it, and what is it called?

> >

> > Gene Gandy, JD, NREMT-P, LP, Evil Scenario Doctor (ESD)

> >

> >

> > ************ *

> > New

> > year...new news. Be the first to know what is making headlines.

> > (http://www.aol.http://wwwhttp://www.aol.http)

> >

> >

> >

[Guest guest]

>It sounds to me like Twiddlers Syndrome, which is the dislodgement

of one of the pacemaker leads, stimulating a different muscle. It is

more common in older women then anyone else.

Welch

> Hi, boys and girls. Ready for a new mind twister? I knew you

were.

>

> You are called to the home of a 70 year old female who complains of

general

> weakness and hiccups that have lasted for the last two days without

relief.

>

> You observe a female patient sitting on the sofa in her living

room. She

> appears to be around 5'6 " tall and looks to weigh approximately 225

pounds.

> She is visibly hiccuping about ever second. She looks to be in

mild distress

> but is able to talk easily between hiccups.

>

> She tells you that she first got the hiccups yesterday, and in

spite of all

> the " tricks " she and her friends know, nothing has stopped them.

She is " at

> my wits end with this. " She further says that when she stands up

she gets

> dizzy and only feels good when sitting or lying down. She was

unable to sleep

> much last night because of the hiccups.

>

> Vital signs are:

>

> Pulse irregular and ranging from 40 to 50 with occasional longer

pauses.

> Respirations about 15 and difficult to count because of the muscle

> contractions in the area of the diaphragm when she hiccups.

> BP 100/60 lying; 98/60 sitting (left arm)

> SaO2 97% on room air

> Tympanic temperature 98

> Blood glucose 104

>

> As you are placing the leads on her chest to do a 12-lead, you

notice that

> she has a pacemaker. On questioning, she states that she got the

pacemaker

> about 7 months ago after experiencing a slow and irregular

heartbeat. She says

> it has been working fine as far as she knows. She denies chest

pain or

> discomfort other than the hiccups, denies nausea/vomiting. Bowel

and urine

> excretion normal.

>

> She states that she takes Atacand for blood pressure, Coumadin as

a " blood

> thinner, " synthroid for thyroid problem, Xanax for sleep, Zoloft

for mild

> depression, and Metanx. She says that she takes her

medicine " religiously " every

> day and has missed no doses.

>

> Her 12-lead shows controlled atrial fibrillation without evidence

of

> pacemaker capture. As you question her further, she reveals that

she believes that

> her pacemaker is a " vertical demand. " You interpret that to be a

ventricular

> demand pacer. A repeat EKG done at double speed again shows no

visible

> pacemaker spikes.

>

> Physical exam reveals:

>

> LOC oriented to person, place, time, and able to answer questions

and relate

> events coherently.

> Skin: pink, warm and dry with non-erythematous lentigo on backs

of hands

> and forearms.

>

> HEENT: normocephalic female with false teeth and glasses.

Pupils equal at

> 4 mm and reactive to light; normal movement following pen, no

nystagmus.

> Tongue and buccal surfaces normal looking, no halitosis. No

hearing aid. No

> masses or lymphadenopathy felt in neck. Jugular veins non-

distended.

> Trachea midline.

>

> Chest: bilateral breath sounds without rales, ronchi, or

wheezes. Heart

> sounds S1 and S2 clearly heard. No pulse deficits. One healed

scar at the

> site of the pacemaker. Normal looking breasts for age. Rhythmic

movements

> coinciding with hiccups, approximately every second.

>

> Abdomen: Obese abdomen with rhythmic movement corresponding to

hiccups.

> Non-tender to palpation, non-distended, no surgical scars. No

palpable

> masses. Denies diarrhea, stomach pain, cramps.

>

> Lower extremities: Obese with varicose veins and mild pedal

edema.

> Dorsalis pedis and tibial pulses not palpable but capillary refill

4 seconds.

>

> Upper extremities: Obese with bilateral radial pulses.

Capillary refill 3

> seconds.

>

> Back: unremarkable

>

> The patient confides that she has been trying to lose some weight

by going on

> a diet and has recently joined a health club and has started

swimming every

> day about a month before. She last swam yesterday morning

before the

> hiccups started. She has been eating and drinking normally. She

denies ETOH use

> or recreational drug use.

>

> After thinking things over for a couple of minutes you think you

know what's

> causing her hiccups. What is it, and what is it called?

>

> Gene Gandy, JD, NREMT-P, LP, Evil Scenario Doctor (ESD)

>

>

> **************

> New

> year...new news. Be the first to know what is making headlines.

> (http://www.aol.com/?ncid=emlcntaolcom00000026)

>

>

>

[Guest guest]

Misplaced pacer electrode, stimulating the diaphragm..??

________________________________

From: texasems-l [mailto:texasems-l ] On Behalf

Of wegandy1938@...

Sent: Wednesday, January 07, 2009 11:39 PM

To: texasems-l

Subject: Re: A new puzzler for the New Year

Not a bad guess, but not the correct cause.

GG

In a message dated 1/7/09 9:52:36 PM,

jpercer@...<mailto:jpercer%40gmail.com> writes:

>

> Stab in the dark: pericarditis - the phrenic nerve runs along the

> pericardium and can become inflamed causing hiccups.

>

> This is very much a stab in the dark, 6 hours til end of shift

>

> Joe percer, lp

>

>

> > Hi, boys and girls. Ready for a new mind twister? I knew you were.

> >

> > You are called to the home of a 70 year old female who complains of

> general

> > weakness and hiccups that have lasted for the last two days without

> relief.

> >

> > You observe a female patient sitting on the sofa in her living room. She

> > appears to be around 5'6 " tall and looks to weigh approximately 225

> pounds.

> >

> > She is visibly hiccuping about ever second. She looks to be in mild

> > distress

> > but is able to talk easily between hiccups.

> >

> > She tells you that she first got the hiccups yesterday, and in spite of

> all

> > the " tricks " she and her friends know, nothing has stopped them. She is

> > " at

> > my wits end with this. " She further says that when she stands up she gets

> > dizzy and only feels good when sitting or lying down. She was unable to

> > sleep

> > much last night because of the hiccups.

> >

> > Vital signs are:

> >

> > Pulse irregular and ranging from 40 to 50 with occasional longer pauses.

> > Respirations about 15 and difficult to count because of the muscle

> > contractions in the area of the diaphragm when she hiccups.

> > BP 100/60 lying; 98/60 sitting (left arm)

> > SaO2 97% on room air

> > Tympanic temperature 98

> > Blood glucose 104

> >

> > As you are placing the leads on her chest to do a 12-lead, you notice that

> > she has a pacemaker. On questioning, she states that she got the pacemaker

> > about 7 months ago after experiencing a slow and irregular heartbeat. She

> > says

> > it has been working fine as far as she knows. She denies chest pain or

> > discomfort other than the hiccups, denies nausea/vomiting. Bowel and urine

> > excretion normal.

> >

> > She states that she takes Atacand for blood pressure, Coumadin as a " blood

> > thinner, " synthroid for thyroid problem, Xanax for sleep, Zoloft for mild

> > depression, and Metanx. She says that she takes her medicine " religiously "

> > every

> > day and has missed no doses.

> >

> > Her 12-lead shows controlled atrial fibrillation without evidence of

> > pacemaker capture. As you question her further, she reveals that she

> > believes that

> > her pacemaker is a " vertical demand. " You interpret that to be a

> > ventricular

> > demand pacer. A repeat EKG done at double speed again shows no visible

> > pacemaker spikes.

> >

> > Physical exam reveals:

> >

> > LOC oriented to person, place, time, and able to answer questions and

> relate

> > events coherently.

> > Skin: pink, warm and dry with non-erythematous lentigo on backs of hands

> > and forearms.

> >

> > HEENT: normocephalic female with false teeth and glasses. Pupils equal

> > at

> > 4 mm and reactive to light; normal movement following pen, no nystagmus.

> > Tongue and buccal surfaces normal looking, no halitosis. No hearing aid.

> > No

> > masses or lymphadenopathy felt in neck. Jugular veins non-distended.

> > Trachea midline.

> >

> > Chest: bilateral breath sounds without rales, ronchi, or wheezes. Heart

> > sounds S1 and S2 clearly heard. No pulse deficits. One healed scar at

> > the

> > site of the pacemaker. Normal looking breasts for age. Rhythmic movements

> > coinciding with hiccups, approximately every second.

> >

> > Abdomen: Obese abdomen with rhythmic movement corresponding to hiccups.

> > Non-tender to palpation, non-distended, no surgical scars. No palpable

> > masses. Denies diarrhea, stomach pain, cramps.

> >

> > Lower extremities: Obese with varicose veins and mild pedal edema.

> > Dorsalis pedis and tibial pulses not palpable but capillary refill 4

> > seconds.

> >

> > Upper extremities: Obese with bilateral radial pulses. Capillary refill

> > 3

> > seconds.

> >

> > Back: unremarkable

> >

> > The patient confides that she has been trying to lose some weight by going

> > on

> > a diet and has recently joined a health club and has started swimming

> every

> > day about a month before. She last swam yesterday morning before the

> > hiccups started. She has been eating and drinking normally. She denies

> > ETOH use

> > or recreational drug use.

> >

> > After thinking things over for a couple of minutes you think you know

> what's

> > causing her hiccups. What is it, and what is it called?

> >

> > Gene Gandy, JD, NREMT-P, LP, Evil Scenario Doctor (ESD)

> >

> >

> > ************ *

> > New

> > year...new news. Be the first to know what is making headlines.

> >

(http://www.aol.http://wwwhttp://www.aol.http<http://www.aol.http:/wwwhttp:/www.\

aol.http>)

> >

> >

> >

[Guest guest]

--- It sounds to me like Twiddlers Syndrome, which is the dislodgement

of one of the pacemaker leads, stimulating a different muscle. It is

more common in older women then anyone else.

Welch