What’s Your Diagnosis? Part I

I had an interesting call the other day and thought I’d share it with you as a case study.  Please feel free to post any thoughts on this call in the comments section.

Vancouver

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It was in the evening and so far the night shift has been busy.  Just as you get back to the station you get another call.  It comes in as a Code 3 for a possible stroke by the side of the highway.  It was easy to find the vehicle your patient was in because a police officer was already on scene.  As your partner pulls the ambulance to a safe location, your pull on your gloves.

You are greeted by the police officer on scene.

You:  “Hey, what’s going on tonight?”

Police Officer:  “I pulled this lady over because she was speeding.  When I went to speak with her, she said she was speeding because she has a headache.  I thought, yeah right, that’s BS.  So I went back to my cruiser to write her a ticket.  When I got back to the car, her face was all drooping so I called you.”

The officer had a concerned look on his face.  You walk towards the vehicle which was pulled over on the side of the highway.  You see a lady in her 30s sitting in the driver’s seat with the door ajar.  Beside her you notice a child, approximately 12 years old.  You introduce yourself to the woman who was in obvious distress.  You ask her her name and how she’s feeling.  As she talks to you, saying she’s not feeling good, you notice slurring, and paralysis on the left side.  To further confirm things, you asked her to give you a smile and the right side of her lips curl up while her left side remains drooped.  You do a grip test and there is obvious weakness on her left side. 

You:  “Do you feel any numbness or tingling?”

Patient:  “No…”

You:  “Any other discomforts you can tell me?”

Patient:  “I don’t know…”

At this point in time, you turn and see your partner preparing the cot for the patient.

You:  “We should get going as soon as we can.”

Partner:  “Sure.”

You:  “Have this ever happened to you before?”

Patient:  “Yes, it happened earlier today.”

You:  “What time?”

Patient:  “Approximately 12pm.”

Just as you were thinking, lets get moving and talk later, a man suddenly appears beside you and starts talking in a loud voice.

Man:  “This has happened SO many times!”

You:  “And you are…?”

Man:  “I’m her husband.  This is like the 7-8th time she has had this!”

You find it odd, the man’s tone of voice and reaction to his wife’s condition was nothing near concerning, but more of frustration.

7-8 TIMES?!?!? What is going on here? 

You:  “You say 7-8 times?  What did the doctor say?”

Husband:  “I’m sick of paying the bills!!  We get a bill every time you take her to the hospital and the doctors find nothing wrong with her.  Don’t take her to the hospital.”

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At this point, what is your working diagnosis?  What are your thoughts on the husband?

———————————————————————————————————————————————————————–

You:  “Well, right now it looks like your wife is having a stroke.”

Husband:  “I know!  The doctors say she has silent migraines that presents as a stroke.  We’re waiting to see a neurologist for the last two months and they’re fast tracking her.  It’s pointless, every time she goes with the ambulance, we get a bill, and there’s nothing they can do for her there.”

You think to yourself:  Hmmmm silent migraine huh?  I never really thought about that.

Husband:  “Look, the first time it happened, I was worried to death, but this is an on-going thing.”

You:  “I understand, but because she is presenting as a stroke, I have to treat her like a stroke.  I need to take her to the hospital.”

Husband:  “No you’re not.  You can’t if she doesn’t want to.”

———————————————————————————————————————————————————————–

At this point, what are you thinking?  Does the new information the husband gives you changes your treatment plan?  How are you going to respond to the husband?

———————————————————————————————————————————————————————–

You turn to your patient.  Throughout the conversation with the husband you notice her getting drowsy and had to talk to her or give her a little shake to keep her alert.

You:  “Do you want to go to the hospital?”

Patient:  “I want to be fixed.”

You take that as a yes and with the help of your partner you load her onto the stretcher.

Partner:  “Code 3?”

You:  “Yeah, lets do that.  I’m ready to go when you are.”

So off you go lights and sirens to the hospital.  En route you gather a history and a set of vitals and this is what you get:

Signs and Symptoms:  Currently no headaches, pt complains of nausea, left side weakness, left facial droop, drowsiness, slight slurr speech.  Symptoms started about an hr ago.
Allergies:  None
Meds:  Levothyroxine (said is for migraines)
Past Med Hx: Migraines
Vitals:  120/p, 100 reg/str, 20 easy, 98% RA,  BG 5.0, GCS 14 (3,5,6), Pupils PERL

As you continue towards the hospital you notice something new.  Her right arm would tremor.  You try calling the hospital’s ER to give a notification but no one answers. 

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What is your treatment plan?  What are your differential diagnosis?  What other questions should you ask?  Is there something about the meds that would cause concern?  Is this really a CVA/TIA or something else?

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Comments
12 Responses to “What’s Your Diagnosis? Part I”
  1. craftymedic says:

    My first thought is that if the husband is right with the diagnosis she shouldn’t be driving, if she’d legitimately been seeing a doctor for this she would have had her license suspended or at least told not to drive (assuming the doctor is responsible). That makes me think he is lying and there’s a potential domestic situation. I would be transporting as per CVA protocol (that’s what it’s presenting as on scene) without the husband (consider bringing the child who is old enough to assist with history). Continue the questioning, including whether CTs were preformed (anyone presenting like this to an ER would have had one done) and what other specific assessments had been done.

    As far as DD, CVA/TIA is definitely high on the list, I couldn’t rule out that the husband is telling the truth, it’s not a common presentation but certainly possible. Levothyroxine is a drug given to prevent the recurrence of thyroid CA (ya I googled that…) and with that information I would be highly suspicious of a tumour. Would open a line of questioning as to CA history for sure.

    • Alex says:

      I think you did everything right. The one thing that I might if investigated is if she had any cardiac Hx despite her age.

      An aquatint of mine had a stroke and he is in his mid 30s. He had a leaking valve that was poorly repaired when he was a child.

      • PocketMedic says:

        Thanks for sharing that Alex, I would never have thought to associate it with a leaking valve since it’s probably not very common.

    • FLMedic311 says:

      Levothyroxine is typically used for Pt’s with Hypothyroidism

  2. T says:

    I would have done the same. If we’re close to a stroke centre and we’re well within the timeline for thrombolyitics I usually transport code 2, all things being equal.

  3. KPA says:

    Just adding to the mix a possibility of an absent seizure, or a focal seizure involving area around the facial nerve as a DD? If symptoms usually resolve and the doctors cannot find any signs of neurological ischaemia it may be due to seizure like activity.

  4. Alex Talan says:

    Focal seizure is a distinct possibility, however, levothyroxine is a drug utilized for hypothyroidism.. So could we also be thinking about a possible OD if she says that drug is utilized for her migraines? Just my two cents.. Because if she’s taking a wrong medication, especially in her confused state.. Compounded by the external stressors of her husband’s attitude towards her pathophysiolgic presentation. I would think the possibilities are CVA/TIA, Drug OD (albeit pharmaceutical), And there is the possibility of ICP due to inflammation of the meninges.

  5. MedicDustin says:

    I would think that there is something else going on here like conversion disorder which can be brought on by stressful situations. Maybe the stress of the Police officer stopping her triggered an episode. As Paramedics we need to expand our knowledge of not so common medical conditions. We sometimes get tunnel vision and treat every patient as they are the same. If it looks like a stroke treat it like a stroke. Your treatment in the ambulance wouldn’t hurt this patient. If this patient was having strokes they would most likely see this on her CT scans.

    • Greatest says:

      I had a similar call like this a few months ago. A neighbour had called EHS for a collapsed patient. We got on scene and noticed a woman in her mid 30’s laying supine on the floor with left sided facial droop and no response to pain stimuli on her left side. Quick set of vitals, and a brief history from the neighbour we get her loaded on the cot – just when her husband pulls up and states that we don’t need to take her and he doesn’t want to pay another ambulance bill because this happens too frequently. He explains that the Dr. can’t explain why this happens and that its a huge waste of time for everyone. Husband goes in detail about its a silent migraine, but has the symptoms of a stroke or seizure sometimes. Nevertheless we transported her to the hospital, due to the fact it presents itself as a stroke.

      • PocketMedic says:

        Thanks for sharing! It’s good to know others have also experienced the same situation. Although in scenarios like this I wish we could help the family out more, but our hands are tied in that we can’t risk not transporting the patient. Must be so frustrating for the family.

  6. Richard says:

    Could be a TIA? Doesn’t leave lasting damage and generally won’t show up on scans. Would account for stroke like symptoms but absence of ongoing issues. Bells Palsy is another but I would ask about how long it has taken for the wife to recover in each of the last 7 episodes.

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