fireflymedic Posted January 19, 2009 Share Posted January 19, 2009 You respond to the home of a 67 year old female who is complaining of severe chest pain and headache who has called EMS herself. Upon arrival, you find the home to be in quite a disarray and the lady says she has difficulty getting around due to arthritis which has been worse the last week particularly in her right leg. She is speaking to you in full sentences, but frequently moaning and complaining about her chest and her head which she states is a crushing quality 8 out of 10 intensity. You do your assessment and find vitals to be as follows : BP 140/94, Pulse 110, Resp 24 even unlabored, SpO2 98% room air. You try to get her up out of her recliner which she states she has been in almost all the time with legs elevated for last two days and she nearly collapses on you due to weakness in her legs. She states reason she called tonight rather than going to the doctor was the chest pain which she thought heart burn and has been treating with tums the last three days increased dramatically and her intense headache. She tells you her medical hx was a brain tumor removed 10 years ago, diabetes, and pulmonary embolisms x 2 about 8 years ago. She hands you a walmart bag full of meds, some of which she is actively on, others she is not. What would you like to do for this lady and what's goin on with grandma? Link to comment Share on other sites More sharing options...
Arizonaffcep Posted January 19, 2009 Share Posted January 19, 2009 Color? Seems like she's able to speak in full sentences...(please let me know if I'm mistaken). What are the meds? My guess is a PE again. Link to comment Share on other sites More sharing options...
okmedic Posted January 19, 2009 Share Posted January 19, 2009 I agree with Arizona, skin color, meds, also 12 lead, stroke scale, O2, IV,FSBS, her daily activities, allergies, ect..? Link to comment Share on other sites More sharing options...
crotchitymedic1986 Posted January 19, 2009 Share Posted January 19, 2009 This is why I didnt mind running nursing home calls, these folks are far more of a challenge than your average 40 year old MI or trauma patient. Start with a full head to toe survey, want a better description of her chest pain, what does the 12-Lead show ? Does she have a fever ? My initial guess would also be PE, but she could have any number of issues, including the flu, MI, return of Cancer, electrolyte imbalance, or even a severe UTI (seriously). Link to comment Share on other sites More sharing options...
firemed665 Posted January 19, 2009 Share Posted January 19, 2009 Not much to say here. Doesn't matter about skin color or any other info. If she is complaining of chest pain 8/10 with no history of trauma and hasn't moved in days you'd better hook her up, treat her with cardiac protocol including a 12-Lead and consider PE protocol if you have one. Even though she seems whiny and her symptoms are probably from sitting in the chair for several days remember it all started with increased pain in her right leg and she does have a history of PE x 2. It's a good chance she may have another PE. Her headache is probably caused by dehydration and possibly low sugar since its a good bet she hasn't been eating right as well. Gotta love getting old. Link to comment Share on other sites More sharing options...
Arizonaffcep Posted January 19, 2009 Share Posted January 19, 2009 Doesn't matter about skin color or any other info. All relevant to assessment. Good assessment = good medicine. Bad assessment = bad medicine. How is she neurologically? Intact with = grips/push/pulls, etc? Off the bat, IV, O2, Monitor. I wouldn't want to go down any specific pathway until I could rule in CVA (as I can't rule out...), or if another pathway presented itself more prominently. Link to comment Share on other sites More sharing options...
jwraider Posted January 19, 2009 Share Posted January 19, 2009 Why has she been sitting in the chair for 2 days? What came first the chest pain or headache? Do a physical exam of her chest and legs. Do her legs have tenderness that suggest a DVT? Did the chest pain change in any other way besides severity? (quality, radiation, constant?) Does it look like a stroke AT ALL? Grips equal? Face equal? arm drift? Speech ok? She denies shortness of breath? Without being an MD and without access to better information provided by in hospital tests I can't see a reason not to treat for the chest pain. Also assuming nothing pertinent came from the above assessments. So: 02 NRB (assuming she looks like an 8/10) ASA 342mg Monitor + EKG BP (140/90) Organize and review PT meds IV access + Nitro SL 0.4mg Transport Blood sugar check Repeat assessments Continue 02 and Nitro, consider morphine. Link to comment Share on other sites More sharing options...
fireflymedic Posted January 19, 2009 Author Share Posted January 19, 2009 Okay kids, I like your thinking so far. Class is now in session. This little lady is not a nursing home patient - she lives at home with her daughter who has noticed a progressive shortness of breath the last two days and tried to get her mother to go to the hospital, but being a stubborn old country woman would not. Prior tumor was non cancerous, treated with surgical removal and 6 weeks radiation. Right leg is slightly swollen and she said pain is primarily behind the knee. She's been in the chair last two days due to leg pain but in general due to arthritis daughter says she doesn't move around much. Currently neurologically intact and within normal limits of someone her age. Well alert and oriented. 12 lead is normal in all leads. Speech is normal and fluid and yes she can speak in full sentences. But yes, she does look sick. Slightly diaphoretic and a little grayish looking claiming she's feeling a little nauseated now with being moved around. This lady is quite heavy (about 300 lbs). Pt's meds are synthroid, lipitor, potassium supplement, fish oil, vitamin D, vitamin E, calcium, clonodine. Also has history of acute kidney failure from 1 year ago. Meds are to take over anterior pituitary function as was damaged by radiation and tumor. So you put her on O2, give some nitro, some asprin, and a little morphine. She states relief of chest pain has resolved to a 2 out of 10, but still states severe leg pain and currently no further headache with those interventions. You're 30 min transport out from a hospital even remotely competent of taking care of this patient - anything else you'd like to do for her? Any thing else you think going on? More to come. Link to comment Share on other sites More sharing options...
jwraider Posted January 21, 2009 Share Posted January 21, 2009 OK get more info about the shortness of breath. Progression? cough? Sputum? Severity? Any recent changes in diet or medications? Does the pain in her right leg feel different (location, quality) than usual or is it just worse? How swollen does each leg look and compare that to normal? Also is one bigger than the other? "synthroid" Does she have hypothyroidism? Did it start after the radiation or before? How do heart tones sound (lol magical question there coming from me)... Any history of "fluid around her heart" ? I'm going to guess she is suffering a complication from secondary hypothyroidism since her pituitary is not working right. She has the following symptoms of hypothyroidism: Poor muscle tone Fatigue Muscle cramps and joint pain Arthritis Weight gain and water retention. Any chance she has a goiter or issues with feeling cold? Complications that I found that result in the severe symptoms she is having (chest pain, shortness of breath, cardiac output) Pericardial effusions (I had to look this up during my internship, it's due to myxedema or leathery tissue) Anemia (HR speeds up to compensate now she's having an MI) Even if I'm right I can't completely rule out a PE Link to comment Share on other sites More sharing options...
fireflymedic Posted January 21, 2009 Author Share Posted January 21, 2009 Okay kids, this patient was actually my mother. Had DVT in saphenous vein. Calf was swollen, slightly red and tender (but I didn't give all that didn't want to give it away). In actuality, she didn't tell the medics or doc that she had a history of PE despite having them twice. Doc got hooked into thinking it was just sciatica (uh yeah - thanks idiot community) and medics dismissed her giving her just O2 on the way up, no 12 lead done until ER. Pt was placed on long term coumadin therapy with maintenance INR of 2 and recovered without further complication. Good job ! Like your aggressive thought process and treatment. Link to comment Share on other sites More sharing options...
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