History Data Panel. Case 024 Myxedema Coma. Presenting Complaint weakness. Person Giving Information paramedic

Transcription

1 History Data Panel Presenting Complaint weakness Person Giving Information paramedic History of Present Illness Mildred Smith is an 88 year-old female who is DNR/DNI, BIBA from home with several days of progressive generalized weakness and altered level of consciousness (ALOC) with no obvious trauma. The daughter reported a recent flu-like illness with increasing lethargy decreased po intake. No further history is available from the patient due to ALOC. The patient's daughter (5 minutes into the case), Jane Smith, arrives and reports if asked) that her mother has a history of CHF, NIDDM, HTN, early dementia, and hypothyroidism, and that she has been feeling sick for the last several days due to a bad flu-like illness, causing low grade fevers, runny nose, nasal congestion, and productive cough of thick yellow sputum (despite having received Influenza and pneumovax vaccines). She states that her mother has been lethargic and not interested in eating the last few days. Furthermore she has appeared increasingly more short of breath than her baseline. Advance directive clarification: The patient is DNR/DNI but not comfort care. She would not object to oxygen, IV fluids, IV medications (including vasopressors), or non-invasive ventilation (eg. BiPAP). However, she would object to cardiac pacing Past Medical History Surgical: partial thyroidectomy Medical: mild dementia, CHF, NIDDM, HTN, thyroid nodule, hypothyroidism, pneumonia Injuries: none Medications: Metformin 500mg po BID. Benazepril 10mg po daily. Lasix 10mg po daily. Levothyroxine 75 mcg po daily. + pneumonia and influenza vaccines Allergies: NKDA Obstetrics: NA Other: Advanced directive on file (DNR/DNI per daughter but not comfort care). Valid POLST form on file Habits Smoking: None Drugs: None Alcohol: None Other: NA Family Medical History Father: Diabetes, Hypertension Mother: Hypertension Siblings: None Other: NA Social Married: Widowed Children: 1 daughter Occupation: Former teacher Education: College Other: Lives at home with daughter. At baseline, she is independent in activities of daily living 2018 American Board of Emergency Medicine 1 of 5

2 Physical Data Panel Gender: 88-year old Female Patient Name: Mildred Smith Weight: 45.0 kg ( lbs) General Appearance: Thin, frail, elderly female minimally responsive Airway: Moaning, +gag, tolerating secretions Breathing: Bilateral breath sounds, no wheezing Circulation: Distant slow heart sounds, weak peripheral pulses (symmetric) HEENT Head: Normocephalic, atraumatic. Thin hair Eyes: PERRL, EOMI, normal conjunctiva, no proptosis Ears: Normal external auditory canals, Tms clear bilaterally Nose: + clear nasal congestion without drainage or epistaxis Throat: Dry mucous membranes, + gag reflex, oropharynx clear, normal dentition Other: No drooling or stridor Neck Partial thyroidectomy well-healed scar, supple, full range of motion Skin Cool, dry, paper-thin, pale skin, without any rashes, wounds, or signs of trauma. No cyanosis. Chest Bradypneic, clear to auscultation bilaterally, no chest wall tenderness Heart Regular bradycardia with distant heart sounds, no murmur, rubs or gallops. +S3 Abdomen Diminished bowel sounds, soft, nondistended, nontender, no masses or organomegaly Genitalia Normal female external genitalia Pelvic Examination NA Rectal Normal tone, guaiac negative brown stool, no masses Extremities Bilateral lower extremity edema: 1+ pitting. No calf asymmetry or tenderness Vascular Weak distal pulses. Cool hands/feet with capillary refill 3 seconds. No mottling Neurologic GCS: Eyes: open to painful stimuli, Verbal: Moaning only (spontaneously), Motor: withdraws to painful stimuli but without localizing Consciousness: Somnolent Cranial Nerves: Pupils equal round and reactive. +corneal reflexes, no facial droop Motor: Moves all extremities with normal tone, withdraws all extremities to painful stimuli but does not localize to pain Sensory: grossly intact Gait and Station: unable to assess Other: 1+ reflexes in all extremities. No clonus. Negative Babinski 2018 American Board of Emergency Medicine 2 of 5

3 Verbal Reports Vital Signs Initial VSs BP 74/45 O₂ Sat 87% Oral/axillary Temp T 34.0 C / 93.2 F Rectal Temp T 32.0 C / 89.6 F Post NC/FM O₂ Sat 92% Post Bipap O₂ Sat 96% Post IVFs BP 82/50 Rules Send if "Administers crystalloid resuscitation" is met Post IVFs > 2L O₂ Sat 89% Post vasopressors BP 86/54 P 45 Post dobutamine BP 78/45 P 45 Post atropine P American Board of Emergency Medicine 3 of 5

4 Post lasix/nitrates Post T4 BP 105/60 P 75 R 15 Rules Send if "Recognition of myxedema coma and treatment with IV levothyroxine" is met Post T3 P 180 R 15 Passive rewarming Active Ext Rewarming 2018 American Board of Emergency Medicine 4 of 5

5 General Guidelines General Scoring Guidelines Score up if: Verification of valid POLST Form (eg. appropriately completed and signed) Passive rewarming is performed Core temperature (rectal or via temperature sensing Foley catheter) is obtained ICU admission Updates to the daughter of her mother s condition, including interventions performed (and those avoided due to advance directives) Multiple point of care glucose checks Score down if: Active external rewarming or active internal rewarming is performed Failure to review or respect advance directives (eg. CPR, cardiac pacing, or intubation) Failure to respect the daughter s desire to be involved in her mother s care and present at the bedside Tube thoracostomy, thoracentesis, pericardiocentesis (daughter objects to all and none are indicated) Failure to reassess vital signs or the patient after interventions No change in scoring if: CT head is ordered to rule out intracranial bleeding or mass or if lumbar puncture to rule out meningitis or encephalitis is performed General Play of Case Guidelines If temperature is requested orally, axillary or skin temp, send 'Oral/Axillary Temp' VSs If temperature is requested rectally or via thermister foley, send 'Rectal Temp' VSs Paramedics give information that the patient is DNR. Examinee should ask the paramedics or daughter if there are any formal advance directives. Valid POLST form will then be supplied to the examinee, completed and properly signed; but examinee must request to see it Daughter confirms the validity of the POLST form if asked and opposes intubation, CPR or cardiac pacing, but she is agreeable to IV medications (including vasopressors and levothyroxine), central venous access, and BiPAP Bedside ultrasound (Rapid Ultrasound for Hypotension) will reveal severely decreased LVEF, mild pericardial effusion without tamponade, and IVC <2cm but without inspiratory collapse. If lung pleura is also visualized, there will be normal pleural sliding, small bilateral pleural effusions and visible lung rockets (ie B-lines). If IV glucagon, hydrocortisone, dexamethasone, or antibiotics are requested, there will be no immediate effect on vital signs Septic work up will be unrevealing (CXR: no infiltrates, UA negative for infection). If CT head if performed it will be unremarkable. Lumbar puncture results will be within normal limits. Rapid influenza swab if requested will be negative. Point of care glucose is critically low and will require IV dextrose. It will not completely normalize until IV levothyroxine is administered. Passive rewarming will improve temperature without any effect on blood pressure send passive rewarming VSs Active external rewarming will improve temperature but also lower blood pressure send active ext rewarming VSs 2018 American Board of Emergency Medicine 5 of 5