Just Plain Ruff Posted August 22, 2011 Share Posted August 22, 2011 All but the 911 ems call - scenario as follows. ERDOC as he was the doctor on this and cannot play unless he wants to do a teaching session after the right answer was given. 911 call on a passout now conscious On arrival find a 43 year old white male, sitting on the side of a hotel bed. Noticeably pale and slightly sweaty. History is patient woke up, went into the bathroom, went pee and started walking back to the bed and became dizzy, nauseous, light headed, some chest pain and sweaty. Patient seems to be in mild distress but otherwise says he feels fine now. Ask away. Link to comment Share on other sites More sharing options...
crotchitymedic1986 Posted August 22, 2011 Share Posted August 22, 2011 Since you seem to imply this was not a usual case, I guess three possible scenarios without knowing any details other than what was presented. 1. I had a rather healthy TV executive who just flew back in from Jamaica, had similar presentation with a B/P of 40 palp, and this guy was like 6'2" 250lbs. He had mixed some drugs and a ton of alcohol on his trip (per his friend, but he would not divulge the drugs for fear of losing his job). Or 2. I say the prostitute slipped a little something in his drink to knock him out. Or 3. He is having a reaction to the cleaning chemicals used by the hotel staff. Link to comment Share on other sites More sharing options...
Vorenus Posted August 22, 2011 Share Posted August 22, 2011 First, of course, the whole round of vitals. Patient history? Illnesses? Similiar episode in the past? Did he have any other symptoms in the past few days/weeks aside from that days? Any regular meds or did he take any in the imminent past? Any drugs, alcohol? How long was he unconscious? Was the passout observed? Convulsion? How much can he remember of the episode? When did he passout? Was he standing, sitting, lying? Any injuries from a possible fall? Pupils? Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted August 22, 2011 Author Share Posted August 22, 2011 Since you seem to imply this was not a usual case, I guess three possible scenarios without knowing any details other than what was presented. 1. I had a rather healthy TV executive who just flew back in from Jamaica, had similar presentation with a B/P of 40 palp, and this guy was like 6'2" 250lbs. He had mixed some drugs and a ton of alcohol on his trip (per his friend, but he would not divulge the drugs for fear of losing his job). Or 2. I say the prostitute slipped a little something in his drink to knock him out. Or 3. He is having a reaction to the cleaning chemicals used by the hotel staff. none of the above First, of course, the whole round of vitals. Patient history? Illnesses? Similiar episode in the past? Did he have any other symptoms in the past few days/weeks aside from that days? Any regular meds or did he take any in the imminent past? Any drugs, alcohol? How long was he unconscious? Was the passout observed? Convulsion? How much can he remember of the episode? When did he passout? Was he standing, sitting, lying? Any injuries from a possible fall? Pupils? Vitals are 140/90, pulse 64, resp - 24, pulse ox 99. Takes metformin, insulin, gemfibrizil passed out was only witnessed by ME, and I'm not sure how long I was out. But when I woke up I found that I had been sleeping in my normal place in the bed. the time I woke up to go pee was 3:40 am. My alarm was set for 0710 I remember getting dizzy, light headed, some chest pain and sweating a bit but after I sat down on the bed and laid back, I remember nothing else other than getting up at 0700. I do remember lying back on the edge of the bed but do not remember getting up to go sleep normally with my head on the pillows. No drugs or alcohol. I cannot tell you what my pupils were like. I didn't check them. Remember this happened to me!!!! Well without the ambulance being called so I'm making up some vitals for the sake of the scenario. Link to comment Share on other sites More sharing options...
Happiness Posted August 22, 2011 Share Posted August 22, 2011 Either its vertigo or a massive ear infection, well maybe. I have had 2 pts in my career that have the same symptoms (never found out why the chest pain) and it was an inner ear infection. Link to comment Share on other sites More sharing options...
island emt Posted August 22, 2011 Share Posted August 22, 2011 There is a syndrome related to this. It has to do with the sudden drop in blood pressure after middle of the night urination causing a sudden fluid shift and compensatory syncopal episode following. Let me wrack my brain for a while.. It sucks to get old and have to search the brain cells for info. Link to comment Share on other sites More sharing options...
DFIB Posted August 23, 2011 Share Posted August 23, 2011 Did the patient pee sitting down and create an orthostatic change by abruptly standing? Link to comment Share on other sites More sharing options...
Bernhard Posted August 23, 2011 Share Posted August 23, 2011 (edited) More questions: Did this ever happen before? Kind and location of chest pain (sharp, oppressive, exact location, wandering, radiating, changing with chest movement)? Known allergies? Illnesses/symptoms the last few days (infect or else)? Recent injuries, accidents? From the medications: known diabetis -> is this correct? Since when? Last time to see a doctor about this? Your normal blood glucose level? Last checked (time, value)? Other known medical problems: high/low blood pressure? Smoker? No alcohol/drugs at the moment -> do you normally (ab)use alcohol/drugs? Since in hotel/travelling: from where (maybe remote places with infection risk)? How long on the road/plane? Stress? Last meal/beverage (contents, time)? Last urine normal or unusual (smelly, red, ...)? Last defecation (time, something unusual)? More measurements/inspections: Blood glucose level (in mg/dl please...)? ECG, 12 lead -> anything to see? Temperature? pharyngeal inspection (signs of infection)? lung sounds? bowel movements/sounds? Abdominal pain/abnormalities (palpation)? too bad you can't provide information about your pupils, so I'm assuming nothing unusual there (-> adequate reactions, no unusual visual effects) short neuro check #1: follow my finger with the eyes (up, down, right, left) -> reduced movement? short neuro check #2: stretch and lift arms in front of the chest, close eyes, try to hold them straight -> muscle tonus, sinking of one or both arms? short neuro check #3: close eyes, try to touch your nose with index finger of both hands (successively) -> muscle tonus, side consistent? short neuro check #4: lift arms/legs (successively) against my pressing -> muscle tonus, side consistent? Preparing transport: "Sir, you have some medical problem, most probably with your circulation (won't rule out neurological or other at this stage, but I won't say that). We can't be sure that you don't pass out any time again in a not so harmless environment. Considering that and you having a known history of at least diabetis, it should be checked and maybe adjusted. We want to take you to the hospital to have more possibilities for a diagnosis and care. Do you agree?" Get appropriate lifting tool (stretcher) near the room/bed. Intentionally let patient step up (slowly, controlled) to get to the stretcher to test if there may be an orthostatic problem. Get him see a hospital with more tools and a lab. Anything else: If not something special on the ECG or things change: no. Just monitoring. Personally I don't even see a reason for an i.v., others may do. Possible diagnosis on my call protocol would be now "situation after beeing unconscious for unknown time, poor general condition, known diabetis", differential diagnoses (depending on findings in above additional measurements): orthostatic disregulation of unknown reason diabetis disregulation (blood glucose level?) myocard related circulation problem (ECG?) infection (temperature?) intoxication (last meal?) neurologic related (recent injuries?) On this stage it could be almost anything. As long as he's stable and willing to come with us, I wouldn't try much to figure. Just gather information on scene, put him on monitoring, get him to a hospital following usual hygienic protocols (here: wearing gloves, desinfecting hands afterwards plus all equipment having direct/indirect contact with the patient - that's at least what we do after each call). I recently had a similar patient with several medical and psychological pre-diagnoses nearly passing out after a short hike, turned out he had an acute noro-virus infection. I don't know if it was this patient, but the hospital we brought him into was closed for more than a week due to a burst in noro-virus infections the day after...glad to have cleaned my stuff after patient contact, the hospital probably should've done that, too... Not to forget: surely hope it is better now, Ruff! Get well soon! EDIT: inserted short neuro checks - don't have the proper englis short terms, so described them. Edited August 23, 2011 by Bernhard 1 Link to comment Share on other sites More sharing options...
uglyEMT Posted August 23, 2011 Share Posted August 23, 2011 Benign Positional Vertigo Ruff the Pt woke at 0340 to pee and doesnt remember getting back to sleep but awoke at 0710? Umm sleep walk much? Sounds like a bad dream, RMA and go back to sleep LOL OK this is my bad post of the month guys and gals.. long shift. Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted August 23, 2011 Author Share Posted August 23, 2011 (edited) There is a syndrome related to this. It has to do with the sudden drop in blood pressure after middle of the night urination causing a sudden fluid shift and compensatory syncopal episode following. Let me wrack my brain for a while.. It sucks to get old and have to search the brain cells for info. Island emt seems to be the winner here. But since I did not get to the hospital that night I won't know if it's truly the right answer but all the symptoms fit. Even my diabetic doctor this morning said that was probably what it was. Now, who can guess the syndrome? Winner gets the Obtuse diagnosis award for the day. Did the patient pee sitting down and create an orthostatic change by abruptly standing? Pee'd standing up. Because of this incident and my wife's insistence on my calling my doc, as well as ERDoc's recomendation, I will be getting a cardiac stress test, EKG and blood work next week. YAY!!!!!!!!! Edited August 23, 2011 by Ruffems Link to comment Share on other sites More sharing options...
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