mobey Posted March 1, 2009 Share Posted March 1, 2009 Called for 32 y/o male UnCx (Diabetic Hx) History of complaint Friend states the patient just showed up at her doorstep yesterday aft noon, after a fight with his spouce. Seemed "normal" not under influence. Pt began feeling ill around 10pm and vomits x1. Complains of tinninus, and Nausea. Skips Insulin shot. Friend goes to bed at 10:30, and pt sleeps on couch. friend awakes at 8am to find friend UnCx (unconcious) on couch. This is a little broke up because I am copy$pasteing from another forum I posted this on a few days back. I decided to go with a different format than the old scenario format, and post it as a call review. On our arrival. Well kept mobile home Pt appears appropriate for age. Pt semi Cx, does not track EMS. Pt supine with torso on couch, legs dangling off, incontinent of urine. Breathing about 36/min & deep, pale, warm, dry. Radial pulse strong, regular. Pt localizes pain. No verbal responce. A/E clear to bases. Afebrile, BP 208/110 P 110 BGL "High". Pupils PERL, SPo2 98 room air. Medications Insulin daily (sorry can't remember what kind) Metoprolol Furosemide Lipitor All meds accounted for, and in pt's name PMHx: Unknown exept for the IDDM Friend sts she has not seen this guy in over a year and seems less than interested what is wrong. She wants him outta the house so she can get her kid to school, and herself to work. Other than about 6-7 puddles of dark brown puke, there is no sign of dehydration, his skin turgor was good, and his arm/hand veins were "Bulgy", his mouth was pretty dry, but kussmals will do that lol. Honestly... his breath smelled like puke. Acidic, and bile. No fruity odor at all. He is vomiting about every 6-8 min now, vitals are unchanged, but he is going deeper into an UnCx state, eyes no longer open without painful stimuli, no incomprehensible sounds anymore. 16G IV in left A/C. NRB, Monitor (sinus tach), Reapeat BGL "High". Transported to local small town hospital with DD of DKA. (I am BLS) more to come soon. Pt. treated in OPD of rural hospital with DKA protocol and Nitro drip for HTN. They brought down the glucose over about 3hrs, via continuous infusion. After sugars were down to 12 (from 37mmol BTW) and all the other imbalances were corrected (potassium) the patients mental status did not change..... in fact, the patient began to have fasciculations/seizure activity. To explain further... the patient would clench his jaw (trismus) and you could see his muscles of mastication begin to fasciculate. Within seconds his shoulders, upper arms, and chest muscles would do the same, this would last for up to 30 seconds, then he would stop and immediatly vomit. He would not regain conciousness, but would go back to incomprehencible sounds and disorganized movement. I can't remember the number anymore but his Creatinine was high as well. Obvioustly we transported rapidly to the city for a CT. I stood behind the radiologist as she looked over his scan and said "I dunno.... take him to the ER". Obvioustly we were monitoring him fairly closely by this point as we sat in the ER hallway, and that is when all heck broke loose (in my books), the "seizure activity" (I am calling them complex partial) began occurring more often and increasing in severity, the patient was vomiting q5min, and quickly spiked a fever. He went from afebrile to 39.6 in less than an hour. The CT looked clear to me..... I have had some exposure to CT & X-Ray's in ACP school, but I am in no way capable of interpreting them. He had 2lt of saline overall, and they started a Nitro drip to bring his pressure down prior to transport. That is all I got. Link to comment Share on other sites More sharing options...
chbare Posted March 1, 2009 Share Posted March 1, 2009 Hard to say. What was the sodium? Was a UDS performed? Take care, chbare. Link to comment Share on other sites More sharing options...
mobey Posted March 1, 2009 Author Share Posted March 1, 2009 Hard to say. What was the sodium? Was a UDS performed? Take care, chbare. UDS? Sodium..... I had a brief look at the labs and potassium, sugar, and creatinine was all that jumped out at me, but like I said... it was like a 5 second skim. Link to comment Share on other sites More sharing options...
chbare Posted March 1, 2009 Share Posted March 1, 2009 UDS: Urine Drug Screen. Take care, chbare. Link to comment Share on other sites More sharing options...
mobey Posted March 1, 2009 Author Share Posted March 1, 2009 Toxicology was negative, not even alcohol. Link to comment Share on other sites More sharing options...
chbare Posted March 1, 2009 Share Posted March 1, 2009 Are you able to obtain any additional follow up? Take care, chbare. Link to comment Share on other sites More sharing options...
spenac Posted March 2, 2009 Share Posted March 2, 2009 Did you administer insulin? I may have missed it if you said so I apologise. Link to comment Share on other sites More sharing options...
ERDoc Posted March 2, 2009 Share Posted March 2, 2009 The tinnitis makes me think ASA OD. Were there any other lab abnormalities? ABG? Serum osms? UA? cxr? Link to comment Share on other sites More sharing options...
chbare Posted March 2, 2009 Share Posted March 2, 2009 The tinnitis makes me think ASA OD. Were there any other lab abnormalities? ABG? Serum osms? UA? cxr? This could explain some of the hyperventilation, altered thermoregulation, and changes in sensorium, and obvious metabolic derangements. Take care, chbare. Link to comment Share on other sites More sharing options...
HERBIE1 Posted May 22, 2010 Share Posted May 22, 2010 Sounds like he has multiple issues going on. Obviously DKA, and noncompliant with insulin, and probably noncompliant with other meds which would explain the HTN. Dark brown emesis- GI bleed? Renal issues? Lot's of issues here. Good medical call. I'd be curious about the diagnosis(es). Link to comment Share on other sites More sharing options...
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