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Thanks! 8)

If there have been no changes in meds (other than the addition of the Levaquin) then I assume the guy is still on Plavix? Perhaps a bleed is the culprit here?

Let's do a few things:

(1) If we haven't already, can we check the BP on both arms to see if they are congruent. Are pulses good in all extremities?

(2) See if the guy looks pale. Ask the staff if he looks any different than normal. While we're at it let's take a look at the conjunctiva too.

(3) Find out if the vomiting is something new or if it has been happening all along. If anyone saw it I'd like to know what it looked like.

(4) Let's perform an abdominal exam. What are the findings?

-Trevor

BPs are the same in each arm. The staff has only known him for 3 days but they do not feel he looks any different. He is still on Plavix. He likes like your typical 80y/o. ABd is soft and nontender. He only vomited once and it did not appear bloody. Stool in the diaper is brown in color.

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Please forgive me, but I'm gonna have to start my assessment from the beginning. It's too confusing for me to "skip" over certain parts that have already been answered.

Alright, let's give this a go.

-Scene Questions

  • Any exposure to toxic gases/hazardous materials?

Any possible ingestion of unknown substances/medications?

Any known falls?

Last time patient was seen?

Has the patient complained of anything recently?

Does the patient take his medications or does the nursing staff administer them?

Any recent visitors?

Any recent surgery?

Has nursing staff or fellow patients noticed the pt. acting out of the normal?

- Mental Status?

-Airway-

-Breathing?

  • -Adequate?

-Any signs of poor oxygenation?

-Circulation?

  • -Any obvious bleeding?

-I'm assuming a (-) radial pulse?

-Skin color/temp/condition?

-Rapid medical exam.

  • -HEENT - Any edema? Pupils? Nasal flaring? JVD? Tracheal deviation? Hives? Cyanosis?

-Chest - Equal chest rise and fall? Any paradoxical movement? Breath sounds?

Heart tones? Hives?

-Abdomen - Any tenderness, ecchymosis, guarding or masses? Hives?

-Pelvis - Stable? Incontinence?

-Lower extremities - (+) PMS in both? Any edema? Hives?

-Upper extremities - (+) PMS in both? Hives?

-Any signs of trauma?

-Vitals

BP, HR, RR, Temp, BGL, Pulse ox, Co2. Orthostatic?

-Monitor: 12 lead.

-Cincinnati Prehospital Stroke Scale?

-SAMPLE history.

-Is the patient complaining of anything himself?

Alright...This could be anything, but my differentials include (but are not limited to):

-MI.

-Shock

  • -Cardiogenic.

-Anaphylactic

-Septic.

-Neurological.

-Hypovolemic.

-Neurogenic orthostatic hypotension

-CVA (rare, but maybe).

-Post-ganglionic sympathetic denervation (I came up with this after some research on Parkinson's and hypotension).

-Pulmonary embolus

-Medication effect /overdose

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Now see, ERdoc, I was going with sepsis because of the recent pneumonia and slightly low temp. But you keep throwing that damn plavix out there, obviously as a hint. Now I have to go do some research....you bastard you...

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Now see, ERdoc, I was going with sepsis because of the recent pneumonia and slightly low temp. But you keep throwing that damn plavix out there, obviously as a hint. Now I have to go do some research....you bastard you...

I didn't say anything specific about Plavix. People were asking about his meds and that was one of them. Then someone asked if he was still on it. It might mean nothing (or it might mean everything).

EMSCadet, I will try to answer all of your questions:

No exposure, no ingestion as far as the nurse knows. The pt is bed bound and has not fallen. The only ones to visit have been several family members (2 sons, a daughter and a brother). Pt was last seen the night before. He does not self-administer meds. No recent surgeries. The nurse has only known this pt for 3 days and he is not any different from when he arrived. There is no family present. Airway is patent and the pt is breathing and maintaining his sats. There is a weak but palpable radial pulse. No signs of trauma. There is no cyanosis or edema. You are unable to perform orthostatics on the pt. No hives or rash. The pelvis is stable. He is incontinent of both stool and urine. Abd is soft, nontender without masses. Vitals were already given. He can only answer yes/no and when you ask him if he is having any pain, he indicates no.

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I didn't say anything specific about Plavix. People were asking about his meds and that was one of them. Then someone asked if he was still on it. It might mean nothing (or it might mean everything).

EMSCadet, I will try to answer all of your questions:

No exposure, no ingestion as far as the nurse knows. The pt is bed bound and has not fallen. The only ones to visit have been several family members (2 sons, a daughter and a brother). Pt was last seen the night before. He does not self-administer meds. No recent surgeries. The nurse has only known this pt for 3 days and he is not any different from when he arrived. There is no family present. Airway is patent and the pt is breathing and maintaining his sats. There is a weak but palpable radial pulse. No signs of trauma. There is no cyanosis or edema. You are unable to perform orthostatics on the pt. No hives or rash. The pelvis is stable. He is incontinent of both stool and urine. Abd is soft, nontender without masses. Vitals were already given. He can only answer yes/no and when you ask him if he is having any pain, he indicates no.

Alright...Well, I'm gonna admit that I'm sorta lost. Possibly a seizure (his mental status might be from being postictal)? CVA is still in my list.

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Given the circumstances, it seems like we have exhausted the H&P. What do you want to do to/with/for this guy? We can even try to get some labs done.

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Alright, let's see it's been awhile since i've been on here but.....did the NH take any labs when he was admitted? If so, are the results back? What I, being only an EMT, would do for this guy, throw some O2 his way via N/C @ 4 LPM(covering bases) ALS Intervention (If on an ALS truck, if not call for ALS assist) Stroke check-out (for me, squeezing of both hands, smiling, sticking tongue out, feet). Transport to hospital, if hospital is closer than medic, or medic is not available.......did I miss anything?

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I am all for shotgunning with labs and diagnostics. :lol: CBC, SMA-12, PT, PTT, INR, CK, Troponin, UA with urine drug screen, a 12 lead was already covered (did not see any specific findings for the 12 lead), portable chest, and CT head w/o. Consider an ABG, ETOH, ASA, and APAP. I will take what I can get however.

Take care,

chbare.

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What is his drug dosing schedule? Is he drinking grapefruit juice? Is he taking his Parkinson's med(s) with food?

What was the 12-lead reading (sorry if I missed a previous answer)?

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I am all for shotgunning with labs and diagnostics. :lol: CBC, SMA-12, PT, PTT, INR, CK, Troponin, UA with urine drug screen, a 12 lead was already covered (did not see any specific findings for the 12 lead), portable chest, and CT head w/o. Consider an ABG, ETOH, ASA, and APAP. I will take what I can get however.

I will give you the following:

wbc 11.2, H/H 32/12.5, plt 220

NA 138, K 3.8 BUN/Cr 24/1.2, Coags wnl, Trop 0.4 (nl for this lab is <0.5), CK 23, UA neg, drug screen neg, cxr as read by the radiologist is clear.

You need to justify CT head, ABG, EtOH, ASA and APAP levels.

Here is the 12-lead.

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