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DartmouthDave

Hard to Swallow & Hard to Breathe

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Hello,

You are dispatched for a 64 year-old female c/o trouble swallowing and SOB.

On arrival you find a morbidly obese female who is diaphoretic with audible wheezing heard. She is sitting in a chair and leaning forward. There is a wheelchair and an electric lift in the corner.

The patient's sister is present. She is the one who called 911. She says her sister was in the hospital for 16 months and didn't want an ambulance called. She also adds that the hospital discharge her sister too early!!

Cheers

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BSI, scene safe!

What's the home like? Clean, messy? I see that the patient isn't getting around so well anymore. Any environmental hazards or clues that might aid in a diagnosis? Medication bottles, potential allergens, etc.

As far as the patient goes, let's have a closer listen to her lung sounds and get her on some oxygen 12 lpm via NRB and a pulse ox. I also want to direct my partner to go ahead and set up an albuterol treatment and and I want to get a full set of vital signs: pulse, BP, SpO2, EtCO2 if we have it available, and let's get her on the monitor as well.

As far as the HPI goes, I'd like to find out time of onset, description of onset (sudden, gradual, what was going on when it happened), if she has a history of respiratory illness and if so what her diagnosis is, if she took anything for the SOB prior to our arrival, any other medical history and allergies. Also, what was she in the hospital for? Had she been on a vent? Any complications during her admission (infection, pneumonia, etc)?

Finally, for the physical assessment, I want to look for tracheal deviation, subcutaneous emphysema, retractions, depth of respiration, scars on her chest (CABG, chest tube, etc), and I want to have a look at her fingers for signs of clubbing or any other signs of pathology (splinter hemorrhages, osler's nodes, etc). Oh, and is she having any other associated symptoms? Pain/discomfort anywhere, etc.

EDIT: Also, what's her airway and tongue look like? Any swelling or obstructions that I can visualize at this time? If there's any excess secretions, we can go ahead and suction those out.

Edited by Bieber

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What has she eaten recently?

Let's pop her on some O2 and get a 12 lead ECG before we do anything else

Standard alphanumeric soup dine in please, we are in no hurry - RR, BP. HR, EtCO2, SpO2, temp

What are her activities of daily living like?

What was she in the hospital for?

Who is looking after her medically wise, does she have a GP, can we give him a quick call and have a chat?

What are her wishes regarding medical care and transport?

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what they said

What was her sister in hospital for?

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Hello,

A general reply for OZ, Kiwi, and Bieber.

The sister is able to provide a good history for you.

She was in the hospital for necrotizing fascitis of her low abdomen and peri area. She required an extensive ICU stay with many complications. It took 8 months before her abdomen was closed. The rest of the time was spent in rehab.

She has been very weak since. Some days she can walk a few feet (chair to bed, ect...) but mostly gets around in an electric wheelchair.

Her medical history: Obese, COPD, MI, CAD, HTN, DM II, Obstructive Sleep Apnea (OSA), OA, Depression, Anxiety, Ventricular Aneurysm, and Dyslipidemia

HPI: She has been home from the rehab hospital for three weeks now. For the past two weeks she has been having dyspnea and wheezing. The dyspnea worsen when she lays back. A few days ago she developed a 'cold' and was coughing up greenish sputum and started on an Abx by her GP.

You physical assessment reveals:

GCS: 15/15 (Anxious++)

Airway: thrush, otherwise normal

Breathing: 28 with increased work of breathing/ pursed lips / indrawing around the clavical and trachea / wheezing+++ / very loud when she exhales / SpO2 is 85% on room air

Circulation:

-->HR: 120 S.Tachycardia

-->BP: 160/100

-->Temp: 37.8 / Soaked in sweat

A faint scar is seen on her neck. Her abdomen is a mass of scars with much of the muscle of her left leg removed. A suprapubic cath is in situ.

Cheers

Edited by DartmouthDave

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Sounds like it's time for a consult with Dr Kevorkian. !

Seriously now: How many million $$$ of healthcare have been spent trying to keep this train wreck alive over the last few years?

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Seriously now: How many million $$$ of healthcare have been spent trying to keep this train wreck alive over the last few years?

Dude that was harsh!

Sounds like it might be a PE?

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Dude that was harsh!

Very. I am sickened. And that takes a lot.

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Dude that was harsh!

It was intended to be!

Sometimes the truth is blunt.

Edited by island emt

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Sounds like it's time for a consult with Dr Kevorkian. !

Seriously now: How many million $$$ of healthcare have been spent trying to keep this train wreck alive over the last few years?

Clearly you have no clue as to what Dr. Kevorkian was all about. He would have NEVER assisted this patient as she is not a "Train wreck" at all.

Her medical history: Obese, COPD, MI, CAD, HTN, DM II, Obstructive Sleep Apnea (OSA), OA, Depression, Anxiety, Ventricular Aneurysm, and Dyslipidemia

Please point out which illness specifically costs millions to keep this lady alive??

Sometimes the truth is blunt.

Yes it is.... You just lost huge credibility. you now look like a completly noncompassionate pompous arrogant prick who has no idea what he is talking about.

Moving on....

Is there any other neuro findings?

Difficulty speaking?

Upper airway adventatious sounds?

Start with 5.0mg Salbutamol.

2G MgSo4 in 100ml saline ran over 10min

Dexamethasone 8mg IM.

Was she intubated?

Trach? (Scar on neck??)

Edited by mobey

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