I while back, I had an interesting call. This is the first part of two posts… Read the call below and see what diagnosis you come up with.
You were watching Emergency a tv series from the 1970s when the phone rang. Your partner went to pick up the phone as you turned off the tv and lugged yourself off the couch.
Partner: “We got a Code 3 for a seizure.”
So off you went, lights and sirens to the call. When you got there, you found an elderly gentleman on a chair, he looked rather flaccid and pale.
You: “Hi, what happened?”
Friend: “Well, we were having a meeting and he suddenly passed out on the ground and was having a seizure…”
You: “Can you describe the seizure to me?”
The patient’s friend imitated jerking movements of the whole body including the tonic-clonic and hypertonic phases. You find out the patient has been complaining of tremors in the right arm for the past several weeks (is new), has never had a seizure before, and had no recent falls. He did however have a stroke in the past. As for medications, he’s taking rabeprazole and plavix.
You: “Hi sir, do you know where you are?”
He can’t answer you properly and is confused…he appears postictal. You decide to get a quick set of vitals while your partner goes to get the stairchair.
- BP: 94/60
- HR: 118
- RR: 24
- SpO2: 97%
- Skin: Pale, cool, diaphoretic
- Temp: 37°C
- Pupils: PERL 3mm
- BG: 5.6 mmol/L
When you get him into the ambulance, you tell your partner to drive Code 3 and you place a nasal cannula on your pt at 4Lpm. Suddenly your patient starts to vomit without warning (he continued to vomit without warning throughout the trip to the hospital). The vomit is clear fluids with a tinge of yellow, no blood.
You notify the hospital then you do a quick neuro exam and found the following:
- Equal grip strength
- No arm drift
- Patient still confused and needs encouragement to respond to commands GCS 13 (4,4,5)
- Patient can look to the right, but needs encouragement and with difficulty can look to the left, cannot look up or down
- Patient has slightly droopy smile
You start a line of normal saline running at TKO en route to the hospital.
By the time you arrive at the hospital you had the patient in a gown and you are sweating like mad. You roll your patient into the trauma bay as a nurse greets you. You give her your hand off report as she comments how it’s so lovely that you got your patient in a gown! As you leave the hospital, you have a diagnosis in mind and look forward to following up with the doctor later to see if you were right.
Feel free to write your differential diagnosis in the comments section. What’s Your Differential Diagnosis Part II will reveal what the diagnosis is and the clues to coming to that conclusion based on information from this post.