Three Case Studies: HELP!?!

[JasonA]

My instructor canceled class, again. So she sent us these case studies. We are not going to be graded on them, so its ok to help me. She said that we are going to talk about them tomarrow night in class, but, for reasons that I would like to keep to myself, I would rather yall go over what I think first. How is my logic? Oh, and I know, she is not good at spelling or gramar, but you can get the idea.

The last two I feel really confident about. The first one.... :shock: :scratch:

Case Study 1

You respond to a 52 y.o. woman complaining of dyspnea, especially bad at night accompanied by a nocturnal productive cough and fatigue. Your general impression is that he is “sick”. You patient assessment reveals that she is tachypneic at 32/min and tachycardic at 110/min. She is also hypertensive at 162/102, A & O x 3 and confused, slightly pale with cyanotic lips, PERRL and has good sensory, motor and a cap-refill or 4 seconds. She feels nauseous, has some abdominal pain, sunken eyes, is weak and has been urinating frequently. She has not had much of an appetite but has been drinking tea, water and some hot chocolate. She is allergic to sulpha drugs, takes lipitor 10 mg, lasix 10 mg and crestor 5 mg daily for hypertension and high cholesterol. She is also diabetic type II and her BG levels read 72. She also takes nitroglycerine for her heart when needed and one baby aspirin daily. Upon auscultation you detect rales her lower lobes.

What is her condition and what is your treatment?

Possible Hypoglycemia/CHF

This patient is possibly hypoglycemic, as shown by a BGL of 72. It is possible that hypoglycemia is the cause of all of her signs/symptoms. Lowered LOC, confusion, and abdominal pain are signs of hypoglycemia. It is possible that she has chronically overdosed on Aspirin. As that would account for most of her signs and symptoms.

She does have possible CHF, which would account for the rales, cyanosis, cough and dyspnea. Her mental status could be altereted due to hypoxia.

I feel that it would not be wise to try and decided which one is the cause. I would transport with highflow 02, and consider D50 or an alternate method of raiseing her BGL.

Case Study 2

You respond to an 80 y.o. man complaining of weakness. Your patient assessment reveals that he is tachycardic at 122/min, tachypneic at 36/min, A & O x 4, diaphoretic, pale, cool and clammy, peripheral edema, ascites and had a bout of epistaxis last night. He is allergic to penicillin, is on Zocor daily, Nitrostat when needed, has a nitro patch, baby aspirin daily, Albuterol 2 puffs morning and night, Flovent 1 puff morning and night, 40 mg lasix and a fiber pill daily. He has not had much of an appetite but has been drinking plenty of fluids.

What is his condition and what is your treatment?

Possible over-use of MDI

Weakness could be any number of things; age related, heart or lung related, it is also possibly an effect of the MDI usage. Tachycardia is a side effect of Albuterol, as is tachypnea. Pale, cool, and clammy skin is an effect of Albuterol, is could also be from his under-lying heart condition. Peripheral edema and ascites are most likely per-existing conditions, and have no relevance to the current situation. This is evidenced by his use of Zocor, Nitrostat, Aspirin, Lasix, and a nitro patch. Epistaxis is a side-effect of Albuterol, as is loss of appetite. His use of two MDIs daily is concerning. In general only one should be used daily, with a fast acting inhaler for sudden onset of symptoms.

Interventions is this situation are limited to high-flow 02 via a non-rebreather mask at 15lmp. Transport.

Case Study 3

You respond to a 3 y.o. female who’s mother is complaining of dyspnea accompanied by a harsh high-pitched cough. You patient assessment reveals that she appears sick is tachypneic at 38/min, tachycardic at 118/min normal blood pressure, is running a fever of 102 degrees has a cough and is drooling and is pale and has cyanotic lips. She is also congested and has signs and symptoms of a cold.

What is her condition and what is your treatment?

Possible Epiglottis

The harsh, high pitched, cough is suggestive of an upper-airway obstruction. The elevated respiration rate suggests insufficient respiratory function. The heart rate is within normal limits for a 3 year old. Fever, cough, and the signs/symptoms of a cold are all consistent with Epiglottis. Drooling is cause by the in-ability to swallow. Cyanosis is cause by the airway being obstructed. Pale is a sign of being sick, also of cyanosis.

There is not much an EMT-B can do in this situation. Provide high-flow 02, via a non-rebreather mask at 15lpm. Transport in a position of comfort. Be ready to provide ventilation via BVM should respirations become even more insufficient.

[JasonA]

We were talking about #1 in the chat. Is it possible that that prevalant condition is Hypovolemia/Dehydration due to the Lasix?

That would account for the high HR, RR, as well as the lowered LOC. Weakness is in there too. The BP is high for compensated shock, but the is on Lipitor and Crestor. Then again, if she is a CHFer, would it even be possible for it to be high?

Cyanonis from poor perfusion, and the sunken eyes. Are abd pain and nauseous a sign of dehydration? Or would you think that would be from the ASA?

[Just Plain Ruff]

On number three you cannot rule out croup also with the high pitched cough.

Does the little girl tolerate the oxygen?

I am assuming that the little girl is the patient but your notes to us state that the 3 y/o's mother is complaining of xyz

These are very open ended scenarios unfortunately you cannot give us much more than what you have given us due to you are going to discuss these tonight or tomorrow night.

If the patient is the little girls mother then you must have a higher index of suspicion for respiratory issues with the mother. Epiglotitis in an adult is a very bad thing. I've taken care of 3 adult patients with epiglotitis and they were really really sick. All 3 were trached by the anesthesia staff due to complete airway obstruction 2nd to epiglotitis. but that's just my experience with these patients.

[ncmedic309]

I would take another look at your differential diagnosis in case 2 and 3...

[Just Plain Ruff]

One other thing, were these descriptions cut and pasted into here or are they your words? If they are cut and pasted then your instructor has more problems than just cancelling class.

[JasonA]

You got EXACTLY what I got. I did correct a few of her spelling errors, but that is it. We are doing Pediatrics/Geriatrics, so I think that she meant the daughter in the last one. Unless being a mom is a serious medical condition, it would be usless information if you were talking about the mother.

Thanks for what you have come up with so far. I will be going over them again after I have thought about them more. NCmedic, I am not really sure what you mean.

[AZCEP]

Nocturnal dyspnea, productive cough, and sweats is not hypovolemia. Respiratory disease process...which one has all three...

For #2, there is a much better explanation for the vital signs than MDI overusage.

#3: With that information you can't rule out one over the other. Unless you look at the "common cold" information a bit deeper. What causes a cold? Which upper airway issue is has a similar causative factor?

I do agree with Ruff, though. Your instructor needs to think about what she has taught you, since these scenarios don't fit with the standard basic curriculum.

[JasonA]

Pnumonia?

Would whatever respritory disease you are thinking of account for the rest of her symptoms?

On #2 my very first though was possible MI. The epistaxis threw me off though, could that just have happened? And have nothing to do with the current issue? Also, isnt his MDI ussages a little excesive, and should that be kept in mind?

On #3, croup is possible. But would that account for the drooling? 3 y/os dont drool.

I am sure that I should have picked it out right off. But my experiance is limited to what I have read in the book, and it has all been thrown at us so quick I am a little overwhelmed. So, Im sorry if it seems like I have no idea, I am just a student, and I really dont. It seems like there are so many things it could be, and especialy with #1, she has so many things wrong. How do you chose what is caused by what, and what the main problem is.

[Just Plain Ruff]

this is what this forum is all about. education and knowledge transfer

I've taken care of plenty of kids who have croup who are drooling. Think of it this way, their throats hurt and they don't want to swallow so they drool. On the other hand I have taken care of kids with epiglotitis and they weren't drooling.

Remember this, what you are taught in textbooks are really the classic signs of the presenting condition. You may have one, or all or none of the symptoms.

Does your book teach you that 25% of all MI's in women(not sure where I got the figure at but I remember someone telling me) present as nausea and no pain??? Bet you weren't taught that.

You are asking the right questions. Take into mind that the information you are getting on this forum comes from people with 3 months experience all the way to 25 to 30 years experience, in the case of our elderly patron Dustdevil. I come from 15 years of experience. Have we seen it all?? heck no, Have we seen a lot though? Heck yeah.

Keep the questions coming.

[chbare]

I think another serious pulmonary disease must be considered as a DDX in patient one. Look at some of the S/S. Very suspicious for a problem we see frequently along the southern border. I think AZCEP is thinking along similar lines.

Ascites is is not a sign caused by albuterol over use. A comorbid disease process may cause this finding, however, the Hx makes no mention of this. This patient may have some complex medical problems. The signs and symptoms suggest problems other than or in addition to albuterol overuse.

I have also seen patients with conditions other than epiglotitis drool. This is a good DDX, but try to think out of the box and consider other causes as well.

I also agree that these scenarios are not appropriate for an EMT-B student.

Take care,

chbare.