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FireEMT2009

80ish year old patient trouble breathing

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You are dispatched to a house for a patient having trouble breathing,her husband and her have meet you at the door. She is having obvious difficuluty breathing. You get her to stand on the stairs behind her.

Treat her!

FireEMT2009

Edited by FireEMT2009

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Scene size up: What does the house look like? Does the yard appear clear of debris, etc? Is the scene safe?

Patient assessment from a distance. You stated obvious trouble breathing. How is it obvious? Do we hear wheezing or obvious pulmonary edema from across the room? Anything coming out of her mouth (sputum, etc) ? Skin condition?

PPE - gloves, face masks if indicated due to severe CHF.

The stairs thing - I'm assuming you mean she's standing in the doorway of her residence with a couple stairs out the front door. Let's get her seated on the stretcher as quickly as possible, I don't like to let respiratory patients stand / walk for a long time.

Upon approaching pt - is she alert and oriented? Any complaints other than shortness of breath? Breath sounds? Medical history, especially anything that would cause a respiratory problem (CHF, COPD, etc)? When did this start? If it's been a while, what made it worse right now that made her call 911?

Have my partner obtain vitals, including RA SpO2, BP, pulse, 3-lead ECG for now, respiratory rate, and probably EtCO2.

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Scene size up: What does the house look like? Does the yard appear clear of debris, etc? Is the scene safe?

Patient assessment from a distance. You stated obvious trouble breathing. How is it obvious? Do we hear wheezing or obvious pulmonary edema from across the room? Anything coming out of her mouth (sputum, etc) ? Skin condition?

PPE - gloves, face masks if indicated due to severe CHF.

The stairs thing - I'm assuming you mean she's standing in the doorway of her residence with a couple stairs out the front door. Let's get her seated on the stretcher as quickly as possible, I don't like to let respiratory patients stand / walk for a long time.

Upon approaching pt - is she alert and oriented? Any complaints other than shortness of breath? Breath sounds? Medical history, especially anything that would cause a respiratory problem (CHF, COPD, etc)? When did this start? If it's been a while, what made it worse right now that made her call 911?

Have my partner obtain vitals, including RA SpO2, BP, pulse, 3-lead ECG for now, respiratory rate, and probably EtCO2.

Nice house, yard cut, clean, spotless. Scene is safe as possible. Extreme trouble breathing, really working on breathing. No audious breath sounds heard upon meeting the patient. Nothing coming out of her mouth. Skin is normal.

PPE- gloves are on, face masks are standing by just in case.

She was standing but you had her sit down on the steps of the stairs to do your assessment. She had to walk down a flight or two of steps to get to the door.

She is alert and orientedX4, tightness in her chest, clear breath sounds, IDDM and HTN, Started earlier when she stood up out of a chair. It started 10-15 minutes prior to your arrival.

BP- 146/94

SpO2- 95% on Room Air

HR- 100 regular strong in radial.

RR- 26 deep, labored.

EtCO2- unavalable.

3 lead EKG- Shows sinus tachycardia at a rate of 100.

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Clear lung sounds and pretty decent O2 sats? I'm thinking there's more to this picture than meets the eye, especially considering she's an older woman and a diabetic. Let's get her moved into the truck ASAP and get a 12-lead EKG. Tell me about this chest tightness, where is it exactly? Does it feel deep or close to the surface? Is it going anywhere? Is it constant/intermittent? Has it been getting better/worse since it started or staying the same? Anything she's done to try and make it better or worse?

Any other history, meds, or allergies? Has this ever happened to her before?

HEENT: Any perioral cyanosis or nasal flaring?

Neck: JVD, retractions, tracheal deviation, subcutaneous emphysema?

Chest: Depth of respiration? Equality of chest rise? CABG scar or palpable implanted defibrillator/pacemaker?

Abdomen: Soft/rigid, any bruising, distention, pain/tenderness?

Pelvis: I presume it's stable since she is able to bear weight.

Posterior: Anything significant?

Extremities: Neurovascular function? Cap refill? Numbness/tingling?

As for vitals, I'd also like:

Pain rating.

BGL.

Treatment wise, let's go ahead and put her on 15 lpm via NC. I'm hesitant to give her high flow O2 if this is a potential cardiac event, especially if she has clear lungs and good sats, but at the same time I want to give her some relief as well. If we need to adjust that later we will. Let's also get an IV of NS TKO.

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What was she doing prior to the event?

Any pain on inspiration in any particular area of the chest?

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Clear lung sounds and pretty decent O2 sats? I'm thinking there's more to this picture than meets the eye, especially considering she's an older woman and a diabetic. Let's get her moved into the truck ASAP and get a 12-lead EKG. Tell me about this chest tightness, where is it exactly? Does it feel deep or close to the surface? Is it going anywhere? Is it constant/intermittent? Has it been getting better/worse since it started or staying the same? Anything she's done to try and make it better or worse?

Any other history, meds, or allergies? Has this ever happened to her before?

HEENT: Any perioral cyanosis or nasal flaring?

Neck: JVD, retractions, tracheal deviation, subcutaneous emphysema?

Chest: Depth of respiration? Equality of chest rise? CABG scar or palpable implanted defibrillator/pacemaker?

Abdomen: Soft/rigid, any bruising, distention, pain/tenderness?

Pelvis: I presume it's stable since she is able to bear weight.

Posterior: Anything significant?

Extremities: Neurovascular function? Cap refill? Numbness/tingling?

As for vitals, I'd also like:

Pain rating.

BGL.

Treatment wise, let's go ahead and put her on 15 lpm via NC. I'm hesitant to give her high flow O2 if this is a potential cardiac event, especially if she has clear lungs and good sats, but at the same time I want to give her some relief as well. If we need to adjust that later we will. Let's also get an IV of NS TKO.

Bieber,

12 lead comes back completely normal. The pain is in the her chest she really cant describe where it is or anything. Oxygen made it little better. The pain has stayed the same. Insulin is her only medication and no known allergies. This has never happened to her before. She also states that she had a mitral valve replacement about 8-10 years ago.

HEENT: Nothing remarkable.

Neck: Nothing remarkable.

Abdomen: soft nontender.

Pelvis: stable.

Posterior: nothing noted.

Extremities: Nothing remarkable.

Pain level- 4-5

BGL-130

15 lpm NC? Do you mean 5 lpm?

You now have an IV running TKO.

What was she doing prior to the event?

Any pain on inspiration in any particular area of the chest?

Sitting in a chair watching tv. She stood up and the pain started.

Ngetative on pain. and she has stated that it pretty much stays the same.

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Sitting in a chair watching tv. She stood up and the pain started.

Ngetative on pain. and she has stated that it pretty much stays the same.

How long was she in the chair for? Did she sit there for a long period of time - 4-6 hours without getting up?

Does she take blood thinners or has she ever had a PE or blood clot in the leg?

I'm leaning towards a blood clot in her leg, breaking off and travelling to her lungs. That would explain most of the scenario. But maybe you have a different thing happening.

Good scenario so far.

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How long was she in the chair for? Did she sit there for a long period of time - 4-6 hours without getting up?

Does she take blood thinners or has she ever had a PE or blood clot in the leg?

I'm leaning towards a blood clot in her leg, breaking off and travelling to her lungs. That would explain most of the scenario. But maybe you have a different thing happening.

Good scenario so far.

No history of PE or blood clots. She takes no blood thinners. She was only in the chair for about 20-40 minutes while eating breakfast with her husband while watching tv.

That is a good field impression. What are some other DDX for this patient?

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No history of PE or blood clots. She takes no blood thinners. She was only in the chair for about 20-40 minutes while eating breakfast with her husband while watching tv.

That is a good field impression. What are some other DDX for this patient?

Well first what makes me think blood clot is that she was sitting in a chair and she stood up and within moments she had the soa.

The other would be her age.

Do an exam on her legs, see if her calves are red or inflamed. Ask her if she has or has had any type of calf pain in the past week or recently.

Does she sit for extended periods of time in that chair or any chair for extended periods of time.

Does she have a family history of high cholesterol?

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Well first what makes me think blood clot is that she was sitting in a chair and she stood up and within moments she had the soa.

The other would be her age.

Do an exam on her legs, see if her calves are red or inflamed. Ask her if she has or has had any type of calf pain in the past week or recently.

Does she sit for extended periods of time in that chair or any chair for extended periods of time.

Does she have a family history of high cholesterol?

Exam shows no reddened or inflammed areas. She has not and any type of pain recently except the shortness of breath. She says she sits for about an hour but gets up and does other stuff,. so no, not long enough to cause clots to form. and family history is unavailable.

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