chbare Posted June 12, 2008 Share Posted June 12, 2008 You are called to the residence of a 67 year old male who is having a seizure. Take it from here. Take care, chbare. Link to comment Share on other sites More sharing options...
AnthonyM83 Posted June 13, 2008 Share Posted June 13, 2008 What is the setting? Describe what I observe when forming my initial impression? I imagine it's hard to airway, breathing, pulse. What type of seizure is happening? Link to comment Share on other sites More sharing options...
chbare Posted June 13, 2008 Author Share Posted June 13, 2008 You arrive and note a middle class neighborhood. You are met by the patient's daughter at the door to his house. She says he has not been well for several months, but has refused to go to a doctor. Over the past several days he has had increased confusion and she found him down seizing. Unknown how long the seizure lasted. The house appears well kept but smells of cigarette smoke. You find the patient supine on the floor. He responds to a sternal rub with slight movement of his arms and legs and moaning. Take care, chbare. Link to comment Share on other sites More sharing options...
irme Posted June 13, 2008 Share Posted June 13, 2008 Still seizuring? Place on O2 NRB, try OPA, Naso if that fails. Looking for my causes early, baslines? Pupils? BSL? Posturing? Ask for a pmhx incl meds and ask her to define confusion. Also how has been "unwell"? Working diagnosis should include cerebral (Needs vitals, pupils, posture), BSL (check them duh, epilepsy (mhx), pseudo (futher assesment) Ill stop for now and await some answers Link to comment Share on other sites More sharing options...
chbare Posted June 13, 2008 Author Share Posted June 13, 2008 You do not note any tonic clonic like activity or repetitive movements. His mental status remains unchanged from the initial impression. Baseline vital signs: P-118, RR-24 and snoring, B/P- 158/92, Temp- 98.9 F, Pulse Oximetry- 83% on room air. Increases to 89-90% on NRB at 15lpm. His daughter states that he takes no medications and his past history is significant for tobacco use (1-2 PPD for 40 years), appendicitis, and a femur fracture 30 years ago. She also states that he has had trouble breathing and has been coughing allot over the past few months. Over the past several days he has been "very confused and not acting like himself." He resisted all attempts by family to make him see a doctor and he was very resistant to talk about his health to family as well. BGL- 82 mg/dl, pupils are 5 mm and sluggish to react bilat. He appears to withdraw from painful stimulus; however, no eye opening is noted and you only note occasional moans with the sternal rub and snoring respirations. Take care, chbare. Link to comment Share on other sites More sharing options...
AnthonyM83 Posted June 13, 2008 Share Posted June 13, 2008 Can you get any other recent symptoms out the family member? Nausea/Vomiting/Fever/ChestPain Other discomfort in head/throat/chest area? Blurry Vision, Tinnitis, Weakness recently? As far as the patient, we'd have to do consider c-spine...does snoring clear up with NPA, gag reflex? airway clear?...skin signs? JVD? Pedal Edema? Lung sounds? Equal rise/fall of chest with good tidal volume? Any recent falls or trauma? Equal withdrawal to pain on both sides? Link to comment Share on other sites More sharing options...
chbare Posted June 13, 2008 Author Share Posted June 13, 2008 Nothing more specific than what his daughter was able to say other than he has had episodes of N/V over the past several days and he did complain of feeling thirsty prior to the decline in his mental status. He does tolerate a NPA and the snoring improves. Pulse oximetry improves slightly to 89-92% on NRB. You note decreased lung sounds in the bases with rhonchi throughout all other lobes. His breathing appears to be on the shallow side but equal movement is noted along with a barrel chest. No known history of trauma and his movement appears equal. (Hard to tell, because he does not move much with any type of stimuli.) Take care, chbare. Link to comment Share on other sites More sharing options...
AnthonyM83 Posted June 13, 2008 Share Posted June 13, 2008 Do I find anything upon a detailed physical exam, particularly around head/neck area? Any other clues (medical papers, pill bottles) as to medical history? My first thought would be some kind of tumor in the throat area that has spread...but not sure how to check that. EKG/12-lead/HepLock/Begin Transport Incontinence? Skin signs? Distal perfusion signs? What does he usually do with his days? Hobbies? What kind of work was he in? Anything of note around the house? Link to comment Share on other sites More sharing options...
irme Posted June 13, 2008 Share Posted June 13, 2008 Hmmm, fits 2/3 cushing sydrome, but no cigar.. I would begin to bag this patient to see if there are any changes to pt's condition. Im still thinking cerebral but another possibility is organophosphate posionion (seizures, rhonci) Have no protocol on the use of atropine for organophosphate poisioning nor am i sure it is it. No bottles etc around? Link to comment Share on other sites More sharing options...
chbare Posted June 13, 2008 Author Share Posted June 13, 2008 Detailed exam of the head, neck, and oral cavity is unremarkable. No additional clues are noted on scene. Incontinence is noted, signs of distal perfusion are noted, additional exam of the skin is unremarkable for any signs of injury. 12 lead: Sinus tachycardia with pathological left axis deviation, right bundle branch block, and evidence strongly supporting a left anterior fascicular hemiblock. No ectopy is noted, normal PRI is noted and no ST or dynamic T wave changes are noted. He worked as a financial consultant for large companies and frequently golfed on his time off. Not so much in the past months, as his ability to tolerate activity decreased with his difficulty breathing. You are able to establish a med lock without difficulty. Organophosphate exposure may be a consideration; however, he is tachycardic and does not show the signs of muscarinic cholinergic stimulation that can be seen with this type of toxic exposure. You are able to bag the patient without difficulty. This is a progressive EMS service in the Land of Oz, and you may have access to additional information or procedures. Take care, chbare. Link to comment Share on other sites More sharing options...
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