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fakingpatience

Hypotension

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I've never written one of these, but lets see how it goes!

Dispatched to residence for the "blood pressure problem." Arrive on scene, find ~50yo obese male sitting at kitchen table in well kept residence. Patient states he has been feeling ill for past 2 days, becoming increasingly weak and dizzy. Also c/o nausea and abd pain. Patient appears very pale. Says he checked his blood pressure at home and found it to be 67/41.

Ready Go!

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First thing check BP bilaterally yourself. Home auto units are notoriously inaccurate.. Full set of vitals History of IDDM? BG=? what meds is he on? Is he compliant? Complete medical HX Chest pain / pressure? Lets get a 12 lead. Probably going to get an IV in just in case. Any vomiting or Diareaha? Has he been eating & drinking regularly? Does anything change when you stand him up? Go!!!!!!

Edited by island emt

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Past medical problems?

What brought on the feeling unwell?

Has there been any vomiting or just nausea?

How has fluid intake/output been?

Any changes in poos? (frequency, colour, viscosity)

Vital signs? (RR, HR, BP, SpO2, temp, ECG, GCS, BGL)

Physical findings? (capillary refill time, skin colour/temperature, turgor, mucus membranes)

Any pain anywhere?

I think this patient is most likely dehydrated from gastro but it could be DKA/HHNK, AAA, MI, the bubonic plague, lots of things ...

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Manual BP 68/42, no significant change in either arm.

No hx of diabetes, BG 118

PMH: End stage liver and kidney failure, pt attempting to get on transplant list. Dialysis 3x / week, last dialyzed yesterday. No other medical hx, does not know what caused the organ failure. Aside from the organ failure, he was a healthy guy!

He is compliant with his medication, sorry I don't remember any of them aside from a liquid medication the pt states helps clear toxins from his body, and causes chronic diarrhea. No recent medication changes.

Denies chest pain/ pressure

EKG shows Sinus tach ~110 with occasional unifocal PVCs. No abnormalities noted on 12 lead

Vomited 1 x today. Has chronic diarrhea. Decreased appetite today.

You stand patient up to sit him on your cot and he starts to wobble, gets a rather glazed look in his eyes. When he is sat back down after resting a minute says he felt much worse standing, was about to pass out.

Your amazing partner gets you an 18 in his L AC.

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lung sounds? abdominal sounds? abdominal palpation reveals what?

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Lung sounds have a trace of rales in the bases, otherwise clear.

Didn't get abd sounds, sorry!

Abdomen is extremely distended, rigid, patient tells you it is normally large but not this large. You can feel a non-pulsating mass in the upper R quadrant.

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Chronic alcoholic circling the drain

Whats his skin look like?

Mucosa?

Sclera of his eyes?

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Full set of vital signs:

BP 68/42

HR 110, sinus tach

RR 18

SPO2 92%

Skin Pale, cool, diaphoretic; no jaundice noted (sclera white). Decreased cap refill. Good turgor.

Temp 36.8* C

Pt c/o severe abd pain, increasing over 24 hour period.

Doesn't know what brought on feeling unless; is ill frequently, attempting to get on list for liver and kidney transplant.

Vomited 1x today, small amount, mainly bile.

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Give him one litre of fluid as a bolus (repeat as necessary), ondansetron and fentanyl prn and take him to the hospital.

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Sounds like liver failure to me, thats why I asked about jaundice.

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