chbare Posted July 19, 2006 Share Posted July 19, 2006 You are called to the residence of a 22 year old male who is not feeling well. What would you like to know? Take care, chbare. Link to comment Share on other sites More sharing options...
NYAEMT-I Posted July 19, 2006 Share Posted July 19, 2006 I would like to know the following: How isn't he feeling well? What was he doing when it started? What kind of medical history he has? V/S, lung sounds, BGL if warranted, abdomen tenderness etc.. I think I would start there and let his answers lead me further.. thanks, NYEMT-I Link to comment Share on other sites More sharing options...
chbare Posted July 19, 2006 Author Share Posted July 19, 2006 NYAEMT-I, He feels weak all over and states he has been coughing allot and has a little abdominal pain. He states his symptoms started several days ago while at home. His medical history is significant for smoking (1 PPD times 6 years) and he states he drinks about a case of beer per week. He is allergic to PCN and denies any other medical problems. V/S 133/88, P 107 strong and regular, RR 22 states he has some chest tightness, O2 SAT 94% R/A, Temp 100.3 F. You note wheezing throughout all of his lobes and decreased lung sounds in the right lower lobe. His RUQ is tender to palpation when quickly assessed. BGL is 119 mg/dl. Take care, chbare. Link to comment Share on other sites More sharing options...
MrSpykes Posted July 19, 2006 Share Posted July 19, 2006 Put him on the monitor, get an abuterol updraft started to take care of those wheezes and see if that clears up the chest tightness. Get an IV- saline lock started on him. Check his pupils, mouth, and throat. Check his cap refill. I am thinking maybe lung CA. Link to comment Share on other sites More sharing options...
chbare Posted July 19, 2006 Author Share Posted July 19, 2006 MrSpykes, monitor shows sinus tachycardia without ectopy. You administer 2.5 mg of albuterol via LVN and initiate vascular access without incident. Pupils are PERL and brisk to react, EOM'S are WNL, no indications of trauma or pathology noted upon external exam. the rest of the HEENT exam is unremarkable. You note that the patient does have a dry cough however. The patient reports feeling a little better after the TX and the wheezing clears, however, lung sounds remain decreased in the RLL. The patient continues to complain of generalized weakness and abdominal pain. Anything else? Take care, chbare. Link to comment Share on other sites More sharing options...
Ridryder 911 Posted July 19, 2006 Share Posted July 19, 2006 Check my status on t.b. test... and ask if Ca runs in the family as well... R/r 911 Link to comment Share on other sites More sharing options...
chbare Posted July 19, 2006 Author Share Posted July 19, 2006 Ridryder 911, he had a TB test done about 1 month ago by the National Guard prior to a short term deployment on a training exercise and it was negative. He states CA does not run in the family. Take care, chbare. Link to comment Share on other sites More sharing options...
chbare Posted July 20, 2006 Author Share Posted July 20, 2006 Since the ABC's are covered, I will allow for a progressive ambulance. Take care, chbare. Link to comment Share on other sites More sharing options...
medic53226 Posted July 21, 2006 Share Posted July 21, 2006 Did he get any new drugs, hx of asthma, family with gall bladder problems or may a is he a tall thin male Link to comment Share on other sites More sharing options...
chbare Posted July 21, 2006 Author Share Posted July 21, 2006 Medic53226, No drugs Rx or otherwise, no known history of gall bladder problems, he is tall and thin however. He asks you if you think all the time he spent out in the field on his exercise a couple of weeks ago could have contributed to his illness. Take care, chbare. Link to comment Share on other sites More sharing options...
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