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Hello,

You are dispatched for a 67 year-old male with a complaint of numb feet and trouble breathing.

On arrival you find the patient sitting in bed with three pillows behind his back. He appears pale, diaphoretic, anxious with increased work of breathing.

The patient had a bad pneumonia two weeks ago which he was on Zythromax. Things seemed to have gotten better and the patient was feeling more like himself. He was able to walk short distances and get up and down the stairs.

Then, over the last 24 hours, the patient experienced a burning sensation in his feet. Which has progressed to worsening weakness in the patient`s legs and very bad lower back pain. Over the last few hours the patient has experienced worsening dyspnea and feels like he is dying.

His family says he is so weak that he can no longer more his legs very well.

The patient has a history of NSTEMI in 2007, CHF, HTN, DM, Dyslipemia, OA, CRF, as well a severe PVD with a Femoro-Femoral Bypass surgery in 2009.

Cheers..

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Hello,

You are dispatched for a 67 year-old male with a complaint of numb feet and trouble breathing.

On arrival you find the patient sitting in bed with three pillows behind his back. He appears pale, diaphoretic, anxious with increased work of breathing.

The patient had a bad pneumonia two weeks ago which he was on Zythromax. Things seemed to have gotten better and the patient was feeling more like himself. He was able to walk short distances and get up and down the stairs.

Then, over the last 24 hours, the patient experienced a burning sensation in his feet. Which has progressed to worsening weakness in the patient`s legs and very bad lower back pain. Over the last few hours the patient has experienced worsening dyspnea and feels like he is dying.

His family says he is so weak that he can no longer more his legs very well.

The patient has a history of NSTEMI in 2007, CHF, HTN, DM, Dyslipemia, OA, CRF, as well a severe PVD with a Femoro-Femoral Bypass surgery in 2009.

Cheers..

Hmmm... a couple of possibilities...

Pulmonary Embolism is high up on my list of suspicion right now, with his HX of PVD and fem-pop bypass, along with the dyslipidemia. AAA is a possibility, especially with the back pain and difficulty moving his legs, as is an MI, but I'm putting my initial thoughts on a PE.

What are his O2 sats? What does an ECG show?

What meds is he taking aside from the Z-max?

His renal failure also makes me wonder... When did he last dialyze? Is he fluid overloaded? Fluid overload doesn't usually cause the issues with his legs, but certainly can cause the dyspnea (and back pain, BTW).

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Very interesting pt. Could we get a set of vital signs?

I am leaning towards some kind of autoimmune response possibly from the infection or the medications.

I am not sure that Pernicious Anemia is an autoimmune disease exactly but it would explain some of his symptoms: anemia coupled with a history or CHF causing increasing dyspnea, burning sensation and progressive weakness of his lower extremities (a worrying sign), his pallor and the diaphoresis.

Another possibility is Guillain Barre syndrome but they usually have an ascending paralysis and possibly pain versus burning and numbness. The respiratory distress in GBS usually comes from paralysis of the respiratory muscles versus the dyspnea that is described here.

Any GI problems or abnormalities with his skin?

Edited by Aussieaid

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Hello,

The has been on Peritoneal Dialysis (PD)for the past 5 years. The patient and his family are very catious and dedicated with his PD. Currently, he has a 4.5% solution in situ. So, his abd is large, distended and full of fluid. Careful records of the patient's PD have been kept by the family and his weight is normal for him at 80kg.

The patient has had trouble with a low Hgb for quite awhile and his "specialist" was considering "shots" to help make more red blood cells.

His skin is pale with a lack of hair on his legs and a crimson red appearance of his feet. His family states that his feet have looked like this for quite awhile.

His current medications are: ASA, Multi-vitamins, Insulin, Calicum, Vit D, Thiamine, T#3 and Metoprolol

His VS:

GCS: 15/15 Anxious and Scared

Pupils: 4mm+Brisk

Arms: Strong

Leg: No movement, flaccid with diminished sensation

Lungs: Clear

Rate: 30-38

SpO2: 84% on RA

EKG: Sinus Tachycardia with an old BBB (120-130 bpm)

Pulse: radials-present / pedials-very weak (feet a cool to the touch)

Temp: 37

GI: distend (fluid in situ) Blood Sugar 15mmol

The patient is c/o 10/10 lower back pain. He has had back pain before but not this bad.

Cheers...

need to run...break is over!! So, pardon the typos please =)

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Hard to palpate for an abdominal mass but any bruits heard? I'm now a little concerned about a AAA or possibly abdominal aortic atherosclerosis which could also have thrown a clot to the lung.

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Ok is this just my computer but when I went to this post there was 2 posts and I thought the topic was dead .. or perhaps folks had "cold feet" about posting, I then clicked reply to ask if Dave had dropped off the planet. But no, in the reply section there are 2 more posts ? huh ? Have I lost it or is there a computer glitch anyway just plain weird.

These "shots for hemoglobin" deal is interesting was that erythropoetin or iron ? And on metoprolol with a BBB as this kinda controversial, especially with severe PVD and then zythromax do you mean zithromax ? This is not typically a commonly used for community acquired pneumonia as first line bug juice, unless C+S has identified something atypical ... anyway lots of metabolic complications here and time for an internal medical consult with corresponding blood workup stat. I would hazard a guess his lytes are out of normals as well, but if this is a "paramedical" type call, its time to pop in a line or 2 in line, O2 to improve oxygenation, get buddy monitored ECG and ETCO2 and a real BP would be nice too, (for some treatment options) I would also drop his bag of fluid and use gravity to decrease his distended abdomen, now with this the Peritoneal Dialysis ... has the patient no urine output and complete Renal Failure ?

Recap: So buddy is looking shocky, 3 pillowed orthopnic, indicative of CHF, thinks he going to die, a high respiratory rate very anxiety, well heck I would be a tad anxious myself if my SpO2 was 84 on R.A. besides the suspected associated anaemic hypoxemia .... this is a load and ski-dandle kinda call.

If I were a betting man I would be very concerned about a AAA / dissection I think for the worst case situation, prepare for that and hope for the least complications. Now if patient was a AAA and high up as well as both extremities being cold, so in the back of my mind thinking that cross clamping would not be an option, for surgical fix and a centre that could do bypass would be a better choice for destination facility, (if I had that option) ... but then this could be a stuck fart too.

If it is this severe back pain and a rapid onset of decreased circulation to lower limbs, the above scenario well frankly speaking this is way over most Paramedic quick fix solutions. I doubt very much I would complicate with narcotic meds at this juncture, as we still have NO BP quite yet.

cheers

ps Aussieaid just me, but I do not think I would include GB as a deferential dx the onset is much slower and from my experience, respiratory involvement is best evaluated with beside spirometry and besides, mortality morbidity from Gillian is very low, this patient is sounding way more acute.

Can we have ABG too if that's not too much to ask ?

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Hello,

Their was consideration or Eprex but the Nephrologist.

The 'Zythromax' is indeed 'Zithromax'. Yes, a typo on mybehalf.

This is based on a patient that come through the hospital that I am working at. It was a confounding case for all parties involved.

Here is a list of Dx we are working with:

1. CHF

2. AAA

3. GBS

4. PE

5. Vascular Crisis

Here is a summation of the physical findings and physical assessment:

1. No weight gain..he is his normal weight

2. Lungs clear

3. Feet are cool...but they are the same that they have been for years

4. He has pulses in his feet....weak but present

5. He had a pneumonia two weeks ago that has cleared up

6. He normally can walk short distances and now he can not more his legs

7. He has diminished sensation in his legs

Also, I forgot to note, that his surgery was a couple of months ago and his recovery was average.

Cheers

PS: A quick response from work (an endless night shift)

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ps Aussieaid just me, but I do not think I would include GB as a deferential dx the onset is much slower and from my experience, respiratory involvement is best evaluated with beside spirometry and besides, mortality morbidity from Gillian is very low, this patient is sounding way more acute.

Can we have ABG too if that's not too much to ask ?

I have to disagree here, Squint, even though the lower back pain is putting it low on my list, GBS is still a differential dx. It can have a rapid onset of hours to days or weeks. It can also cause clots and autonomic dysfunction leading to labile hemodynamics. It may have a low mortality because you can support pt's through it with assisted ventilation when necessary but if it has progressed to this point undiagnosed it constitutes a medical emergency none the less. I have cared for a number of patients who had long ICU stays with mechanical ventilation and not all of them were a slow onset to respiratory failure. Besides if the patient is in respiratory failure I would not be waiting for a bedside spirometry test for a diagnosis before I intubated them.

I am leaning more towards a AAA/dissection scenario though because of the significant back pain with possible abdominal aortic atherosclerosis causing a pulmonary embolus. His co-morbidities definitely muddy up the picture. He could have paralysis from a spinal clot or motor neuron dysfunction.

P.s. I don't think we would have the luxury of an ABG in the field! ;)

So definitely high flow O2 (NRB). I would drain the abdomen and see if that helps with his respiratory status along with the O2. If not then perhaps some CPAP with (depending on his BP- Do we have one, Dave?) some narcotics for pain control and sedatory effects for the CPAP. If all else fails RSI and intubate.

2 IV's with fluids TKO until we get a BP reading and a better idea of what might be going on here.

12 lead on the way to the hospital.

Hope your shift's not too busy, Dave!

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Hello,

Good grief.....I am cringing reading my last post.

No...just the endless night shift.

His BP is 160/80

Off to bed.

Cheers

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I have to disagree here, Squint, even though the lower back pain is putting it low on my list, GBS is still a differential dx. It can have a rapid onset of hours to days or weeks. It can also cause clots and autonomic dysfunction leading to labile hemodynamics. It may have a low mortality because you can support pt's through it with assisted ventilation when necessary but if it has progressed to this point undiagnosed it constitutes a medical emergency none the less. I have cared for a number of patients who had long ICU stays with mechanical ventilation and not all of them were a slow onset to respiratory failure. Besides if the patient is in respiratory failure I would not be waiting for a bedside spirometry test for a diagnosis before I intubated them.

I am leaning more towards a AAA/dissection scenario though because of the significant back pain with possible abdominal aortic atherosclerosis causing a pulmonary embolus. His co-morbidities definitely muddy up the picture. He could have paralysis from a spinal clot or motor neuron dysfunction.

P.s. I don't think we would have the luxury of an ABG in the field! ;)

So definitely high flow O2 (NRB). I would drain the abdomen and see if that helps with his respiratory status along with the O2. If not then perhaps some CPAP with (depending on his BP- Do we have one, Dave?) some narcotics for pain control and sedatory effects for the CPAP. If all else fails RSI and intubate.

2 IV's with fluids TKO until we get a BP reading and a better idea of what might be going on here.

12 lead on the way to the hospital.

Hope your shift's not too busy, Dave!

Damn you Dave .. now we get a BP ! :angry:

cheers

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