Asysin2leads Posted October 7, 2008 Share Posted October 7, 2008 Okay sports, I haven't done one of these in a while, so here it goes. You are dispatched to a 911 call for a patient who could only tell the dispatcher that "Something was definitely wrong with him, but he didn't know what." It is a warm autumn evening and the temperature is a pleasant 70 degrees out. You are met at the door by a 30 year old male, dressed in several layers of clothing, shivering violently, with teeth chattering. It is hard to get a full answers from him because of the shivering, but he states he woke up feeling fine, later in the day had some muscle aches but thought it was due to doing some physical work, had taken some pain medication and eaten a normal dinner. When he was about to go to bed, he suddenly felt extremely cold, and started shivering uncontrollably, as he is now. He does have a history of a recent routine surgery to remove a cyst from his sacral area, which left an open wound that he had been following instructions to care for and allow to drain and heal, no complications or infections had been noted. He had also been prescribed pain medication (Vicodin) for the pain associated post surgery, and had been taking approximately 3 every day, but had cut down to 1 a day yesterday. He has no other pertinent medical history, takes no other medications, and has no allergies. VS: HR: 110, BP:122/82, RR:20, SPO2: 98%, EKG: hard to get tracing due to artifact, appears to be Sinus tachycardia, Temp: 98.6 BGL: 110 PE: PERRL, no cyanosis, no JVD, trachea midline, no accessory muscle use, equal chest expansion, lungs clear bilaterally, abdomen soft, non-tender, no incontinence, PMS present x 4 in extremities, no edema, skin is slightly cool, dry. No obvious DCAP-BTLS noted. You place the patient on oxygen, establish an IV, and transport him to the hospital where he had his surgery done recently. The transport is uneventful, his shivering does stop, but only after turning the heat full blast in the back of the ambulance. What do you think is going on? Link to comment Share on other sites More sharing options...
SANDMEDIC Posted October 7, 2008 Share Posted October 7, 2008 What I was thinking from the get-go. If the patient was febrile we might be in a different boat. After looking around here is what I found. If a patient which has been taking regular Vicodin & stops taking Vicodin, he or she will experience Vicodin Withdrawal within six to twelve hours but the symptoms are usually not life-threatening. The intensity of Vicodin Withdrawal depends on the degree of the Vicodin addiction. For example, the symptoms of withdrawal from Vicodin may grow stronger for twenty-four to seventy-two hours and then gradually decline over a period of seven to fourteen days. The symptoms of Vicodin withdrawal include but are not limited to: restlessness muscle pain bone pain insomnia diarrhea vomiting cold flashes goose bumps involuntary leg movements watery eyes runny nose loss of appetite irritability panic nausea chills sweating Link to comment Share on other sites More sharing options...
Arizonaffcep Posted October 7, 2008 Share Posted October 7, 2008 How was the surgery done? Was it local or general? Also, how long was he in the hospital for it? What are his current labs? Link to comment Share on other sites More sharing options...
Kaisu Posted October 7, 2008 Share Posted October 7, 2008 My first thought is an endocrinal issue - hypothalamus or possibly thyroid problems. Link to comment Share on other sites More sharing options...
firedoc5 Posted October 7, 2008 Share Posted October 7, 2008 At first I was going to mention low sodium, but he's got too much going on, so that blew that out of the window. Any ETOH? Vicodin + ETOH = BAD. What about his fluid intake? Did he try drinking coffee or hot tea to try and get warm? Exactly what was his surgery? Any chance of Staff Infection? (I know, I'm reaching) Link to comment Share on other sites More sharing options...
mobey Posted October 7, 2008 Share Posted October 7, 2008 Any chance of Staff Infection? hahaha Staph Link to comment Share on other sites More sharing options...
ncmedic309 Posted October 7, 2008 Share Posted October 7, 2008 It's pleasant outside - how about inside the residence? Has he ever had a case of "the chills" before associated with any cold or flu-like illness? I would do a complete neurological exam on him, very detailed and to the point. If this is anything significant, I'm thinking along the lines of a neurological or metabolic event. I would expect to see some different vital signs, but it could still be early yet. What else do you have for us? Link to comment Share on other sites More sharing options...
Asysin2leads Posted October 7, 2008 Author Share Posted October 7, 2008 Great responses! Here's some more information and to answer some people's questions. The surgery was an out patient procedure done with sedation via midazolam and local anesthesia of the surgical area. The patient's residence was the same as the ambient temperature, clean and well kept. The patient also states he did try very much to warm up, drinking some herbal tea, taking a warm shower, but felt the water hitting his skin made his aching worse. Follow up... You see the patient the next day after he has been admitted to the hospital. He is asleep in bed with with an antibiotic infusion. He has thrown all of his bedclothes off and his hospital gown in soaked through with sweat. BP: 100/82, HR 114, SP02: 98%, RR: 16, Temp: 103.0. You bribe the nurse into violating all laws regarding patient privacy and she tells you that the patient today complained only of some diarrhea, abdominal cramps, and a headache, no nausea or vomiting, stated no one around him had been sick, and a surgical consult showed no obvious signs of infection at the wound site. His chest x-ray was clear, he had no pain in the kidney area, his urinalysis was normal, and his bloodwork showed only a slight shift in white blood cell production. He had slightly low electrolytes consistent with a high fever, but nothing else significant in lab results. Any more ideas? Link to comment Share on other sites More sharing options...
ladybear Posted October 8, 2008 Share Posted October 8, 2008 what do you want to bet this guy is gonna get a spinal tap? Two things there to get me on that one. the location of the cyst removal.. and the temp without a cause. Link to comment Share on other sites More sharing options...
chbare Posted October 8, 2008 Share Posted October 8, 2008 I assume we are talking about a left shift? Segs, bands, or a manual differential available? Abdominal exam: tenderness, referred pain, bruising, pulsatile masses, etc. Do we have a KUB/flat plate, AAS, or any type of abdominal/pelvic radiography? Not that we would usually find perforation or bowel obstruction on a KUB. Look for air under the diaphragm and for signs of bowel obstruction or perforation. How is his neurological status? Any neck pain? Does he describe the headache. Pupils and EOM's? Is photophobia present? Is the cranial nerve exam intact? Somebody mentioned doing a LP. What do we need to rule out prior to performing a LP? Take care, chbare. Link to comment Share on other sites More sharing options...
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