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Ace844

WADAO with N/V/ HA

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What is going on here?

Could be about anything from a horrible migraine to a cerebral aneurysm to brain masses.

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It's "scotoma", not "scatoma". A "scatoma" is an accumulation of feces that appears to be a tumor (http://www.fasthealth.com/affiliates/h_ths_nm/dictionary/s/scatoma.php).

To save others the trouble of looking those words up: Scotoma is a blind spot, and diplopia is double vision (from www.thefreedictionary.com)

Thanks, I misspelled the word I meant Scotoma, I just spelled it wrong, my apologies. Thanks for the definition.

As to the patient:

Vital signs? (Do I need to explain why I want to know those?)

Not the basic ones, but answering all the ?’s would be helpful. There are soem who are just starting to learn which may read this.

Equal grip strength? How are her pupils? Confusion? Any other signs of CVA/TIA?

The pt has = grips, pupils track equally, are sluggishly reactive, at approx 6mm bilat, but pt notes she does have transient scotoma, and occasional diplopia.

What was happening before all this started? Was she sick? Was there any trauma? (just ruling things out)

Is she orthostatic?

She was walking with her boyfriend down the road smoking; she felt weak, and dizzy then got this loud rhythmic pounding in her ears. She had to sit down for 10 mins. Then, was able to continue. The sx’s resolved and later came back as mentioned in the first post while watching TV and drinking coffee and smoking cigarettes. No recent trauma and she is orthostatic.

Dizziness, vomiting, visual disturbances and head pain are all indicators for some sort of problem in the brain. As mentioned above, the combination of smoking and BCP raises her risk for blood clots, which could occur or travel to the brain, so I would be considering that as a possibility, which is why I'd like to know about the grip and pupilary response. I'd want to know about recent trauma and what was happening when this all started because a head injury could also cause these symptoms.

I'm also wondering if this is some sort of hypovolemia issue (hence the question about orthostatics) - the vomiting, dizziness and visual and aural disturbances could be related to this. Perhaps not if she has those symptoms while lying down as well, but it's something I'd want to consider.

Great rationale and thoughts, what else would be on your DDX?

BTW - that service doesn't run dual response anymore. For a patient like this one, they'd probably just have send A52 for "the transport" - they'd be lucky if the dispatcher was motivated enough to give a CC.

Ok, it was purely an example, and your saying they don’t utilize ALS in this system anymore??? :!: :shock: :lol:

EDIT: Apparently a bunch of us are writing at the same time - there are some entries that already cover some of this that weren't there when I started. My apologies for the redundancy of some of this.

No problem,

Hope this helps,

ACE844

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[marq=up:24879ae760]

[marq=left]"This is ******* FD brocasting a still alarm for E-1, A-52, P-26, to 5222 River ST on the 2nd for a 22yo F not feeling well."[/marq:24879ae760]

You arrive in a nice suburban neighborhood to at the same time as the PD, and fire. Mom meets you just inside the door and says

You bring all of your equipment to the second floor where you find your patient lying supine on her bed. Her mom tells your partner the followign info.; your pt has a hx of ectopic pregnancy (5 mos ago), HPV, migraines, and she smokes. She takes birth control pills and imitrex for the migraines, and has no known allergies.

Upon patient contact you find an obese 22yo patient with pale, hot dry skin, writing on the bed holding her head, and her eyes are tightly shut. You initally gather the following information. She started feeling weak and dizzy about a day and a half ago. This was followed by consistent migraines which she has been unable to relieve with tylenol, alieve and imitrex. Last night she states she started vomiting ( has vomited 4x total large amounts)and noticed that she was having trouble seeing, as well as occasionall loud pounding in her ears. When she tries to stand she states she feels very dizzy.

What is going on here?

HPV postive ..........i say that she could have cancer of the neck or head which is one of the effects of this STD. Thyroid is another cancer to look at here too.... but with the neck and head could be

Why do you think that?

she smokes so this increases her risk for cancer the H/A wasnt relieved with tylenol or imtrex.

HPV-induced cancers often have viral sequences integrated into the cellular DNA. Some of the HPV "early" genes, such as E6 and E7, are known to act as oncogenes that promote tumor growth and malignant transformation.

What else would you like to know?

any previous history of cancer or abnormal pap smears abmornal labs list of current medications that might have been over looked.,,,,, any family hx of cancer....is she likely to be pregnant now......vitals i want to know her vital signs..... pupils size

any enlargement of the throat or neck........is she senstive to light? ...any possibility of DVT due to the smoking and BC pills..

What are your assessment ?'s.

vitals lung sounds puplils abd sounds paplate abd.....put on monitor iv O2 transport in a positon of comfort...

Whats your clinical impression?

i say she has come kind of cancer thryoid or brain realated to the metastis of the HPV she has

If your an ALS provider; how would-do you utilize your BLS?

OMG i will get killed for this one........GOFERS........

Do you triage down, and clear, or ALS the patient, and why?

ALS....due to history ........had previous tubal pregnancy ..... severe headache vomiting......iv to releive dehydration....monitor just to check for changes in route in case it might be cardiac related...

What do you do for this patient and why? I want to not only know the treatments you would do, but why you chose those options over any other. YOU ARE WRONG (EVEN IF YOU ARE RIGHT) IF YOU DON'T EXPLAIN YOUR ACTIONS. The purpose of this is to make sure not just the "this is what we do" but the "this is why we do what we do" of EMS. Also list any questions and their relevace to your assessment. What's your DDX? IF your BLS what's you Rx, ALS, list yours as well...

Let the scenario begin.....Good luck,

ACE844

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itku2er,

Great thought with the HPV, but is this your final DX? Also ABD exam begnign and the pt has No enlargement of the throat, has an abnormal pap 2nd to the dx of HPV. See the above 3 posts for the rest of the P/E-H&P findings.

ACE

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OK....keeping things simple

res-26,pul-116 sinus tach,b/p-190/100, ls clear,skin-p/h/d,

n and v, dizziness, 2 weeks menstruation

based off of the info given thus far I'm going to have to start an infection of some kind.

i would need to ask more about some possible exposure issues.....where does she work, what does the house look like, her hygiene and appearance, what are her habits......

how does her abd present, any tenderness, masses, any discharge noted

what are her orthostatci v/s? need a d-stick

I'm also wondering if she is just lying still or any rocking back and forth?

any noted rash, can she touch her chin to her chest?

at this point it could be so many different issues to choose from, to make a guess. my thoughts go from the dreaded meningitis (which may be the easy answer i think....ace, lol), but how about appendicitis that has exploded long ago. for now I'm sticking with infection of unknown origin.

I'm going to transport als, because that's what we do here...period, i don't have any other options

treatments for now are going to be : iv, EKG, o2, trans in poc, and wait for further info

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OK....keeping things simple

res-26,pul-116 sinus tach,b/p-190/100, ls clear,skin-p/h/d,

n and v, dizziness, 2 weeks menstruation

based off of the info given thus far I'm going to have to start an infection of some kind.

i would need to ask more about some possible exposure issues.....where does she work, what does the house look like, her hygiene and appearance, what are her habits......

how does her abd present, any tenderness, masses, any discharge noted

what are her orthostatci v/s? need a d-stick

I'm also wondering if she is just lying still or any rocking back and forth?

any noted rash, can she touch her chin to her chest?

at this point it could be so many different issues to choose from, to make a guess. my thoughts go from the dreaded meningitis (which may be the easy answer i think....ace, lol), but how about appendicitis that has exploded long ago. for now I'm sticking with infection of unknown origin.

I'm going to transport als, because that's what we do here...period, i don't have any other options

treatments for now are going to be : iv, EKG, o2, trans in poc, and wait for further info

"mad"

great points points, but one clarification. She has 2 weeks until she expects to beging menses...

Her orthostatic v/s's are lying 190/100, sitting 208/100 standing 220/108...

Her appearance is clean and obese and the house is well kept and clean, like you would expect an avg middle class house to be

ABD exam benign

0 discharge, and FSBS as noted is 80

No rash, no nuccal rigidity, she can touch her chin to her chest fine.

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Since this is the magic ambulance, can I get a pregnancy test, CBC, and a set of blood cultures? Also, palp. the chest, arm pits and neck looking for lumps or tenderness (looking specifically for swollen lymph nodes). Depending on the pregnancy test, I would like a CT of the head, neck, chest, pelvis, and abd. Also, is she A/Ox4 and what is her temperature? When was the last time she urinated, is she currently peeing more or less then normal (both in terms of frequency and volume), does it hurt, and is it more cloudy then normal? (looking mostly for dehydration, but who knows what can come up).

The blood tests (elevated white blood count?) and lymph nodes are to r/o infection, the pregnancy test is in part to see if I can do a CT (radiation and fetus is not a good combination), and the CT is looking for organ specific inflammation as well as.

Another use for the CBC would be to test for dehydration. Even with good orthostatic BP, high BP, If both RBC and WBC are both elevated, it could be due to low plasma levels. I'm not too thrilled with her skin signs.

Finally, how is she doing with the extra O2 and the ice packs?

Depending on the results of the CBC and the urine tests, I think it would be time to open up the IV for some fluids. The trick is going to be to rehydrate (and hopefully have her start cooling down naturally) without elevating her blood pressure any more.

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"TechMedic05 wrote:

Onset is questionable [detailed questions below] - however the 'migraine' without relief is not exactly a good sign, as well as the assumed weakness, dizziness and nausea she is experiencing.

Good point, care to carry that further? "

No, not really. :-P Either her migraines have changed [be it type, location,etc.] or simply become refractory.

All things mentioned, and after much research [Have to look at things, I ain't that smart. tech or not, wiseguy :-P] her symptoms do mostly fit the description for a Basilar Migraine, however...I still want to see who's next to that in the line up.

Understanding she's not orthostatic, whats her temp? Any nystgmus present? When the patient was up and about last, any gait disturbances? Perhaps better judged by a family member.

Can we get a better description of the dizziness? circling, room moving, falling?

Oh, and I can't fit it in right now, but I'm thinking smoking may play a role, too. G'd'dmmned suicide on the installment plan.

More to come tomorrow.

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Since this is the magic ambulance, can I get a pregnancy test, CBC, and a set of blood cultures?

NA+ : 120

K+: 3.4

Cl: 90

Glu: 78

BUN: 12

CRE: 1.2

WBC: 10

RBC: 14

PLT: 380

HGB: 12

HCT: 38,000

B-HCG: -

Blood Cultures: Pending, expected results in 24-48 hrs….

Also, palp. the chest, arm pits and neck looking for lumps or tenderness (looking specifically for swollen lymph nodes).

No tenderness, or rigid nodes palpable, no lumps present on P/E

Depending on the pregnancy test, I would like a CT of the head, neck, chest, pelvis, and abd.

It sounds like your using the radiological studies to go on a ‘hunt’ and help you make a DX. There is a downside to doing this among them is unnecessary additional radiation exposure and potential complications with contrast media. Which BTW you dodn’t mention which of any of the CT studies you wanted with or with out contrast, IVP dye, etc…

That aside, all of the CT’s were – for abnormal anatomy of findings.

Also, is she A/Ox4 and what is her temperature? When was the last time she urinated, is she currently peeing more or less then normal (both in terms of frequency and volume), does it hurt, and is it more cloudy then normal? (looking mostly for dehydration, but who knows what can come up).

She hasn’t urinated in 16+ hrs, she has had no PO intake in that time as well., her temp is 100.8 F

The blood tests (elevated white blood count?) and lymph nodes are to r/o infection, the pregnancy test is in part to see if I can do a CT (radiation and fetus is not a good combination), and the CT is looking for organ specific inflammation as well as.

Another use for the CBC would be to test for dehydration. Even with good orthostatic BP, high BP, If both RBC and WBC are both elevated, it could be due to low plasma levels. I'm not too thrilled with her skin signs.

Finally, how is she doing with the extra O2 and the ice packs?

Good rationale for the tests except for CT. Please see my response above. As for the ice packs and O2, please read my next post below. Great thoughts and effort.

Depending on the results of the CBC and the urine tests, I think it would be time to open up the IV for some fluids. The trick is going to be to rehydrate (and hopefully have her start cooling down naturally) without elevating her blood pressure any more.

Great thoughts..

ACE844

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