Alright, medfags of Sup Forums. Let's test your knowledge. Yesterdays thread was pretty fun. Lets start with a classic.
A 61 year old caucasian male enters your ER complaining of severe chest pain.
He describes it as a sharp pain that radiates down his arm. The pain is a 10/10. He states the pain gets much worse when he breathes. He is sweating, has nausea, and is very anxious.
When you question him, he says he was recently discharged from the hospital 3 days ago from a heart attack he had 5 days ago. He states the pain is almost the exact same as when he had the heart attack. He states he had a stent placed in his circumflex artery. The procedure had no complications. Other than the recent MI, your patient has no significant past medical history.
Upon physical examination, you notice he is indeed sweating, has a slight fever, and is tachycardic. His respiration rate is low however, as it is very painful for him to breathe.
What do you do next on your physical examination?
John Allen
Put finger in butt, jerk his peen
Jonathan Ortiz
Anal wink reflex intact. Penis is flaccid. Nurse rips you away from the patient and you're escorted out of the ER by security.
Needless to say, your license is now in jeopardy and you don't have a job.
Connor Carter
EKG
Josiah White
EKG shows diffuse ST elevation throughout.
Now what?
Carson Jackson
tell him he's gonna die and should probably fuck a trap before he dies cause that's my fetish.
Adam Gonzalez
Prinzmetal angina? I'm just studying to be a physiotherapist I'm trying
Aiden Hernandez
No one hears you say that.
Wrong. Perhaps there is more to be done on physical examination? Something more simple? What about asking him more questions about the pain?
Luis Ross
Ask him is his pain stingy or numb I don't really know the phrases in english. Anyway gotta go man good luck.
Isaac Nelson
1)Ask him of he's taken any medicine or dick pills.
2)start assistant with his ventilations @ a rate of 1 breath every 5-6 second
3)check for JVD/Edema or any CHF.
4) Give him aspirin and nitroglycerin.
5) Transport
>Barely started paramedic school. Any tips and advice would be appreciated.
John Barnes
No numbness or tingly feelings (i'm assuming thats what you meant)
1) He doesn't use dick pills 2) Your patient is fully awake, alert and oriented. Why try to breathe for him? You try anyways. He is noncompliant and when you convince him to allow you the pain is intolerable. You stop breathing for the patient. 3) No JVD or edema 4) Doesn't help the pain 5) Transport where? He's at the ER already.
THINK! What is something very simple that I didn't give you in the physical exam?
Remember OPQRST! What did I leave out?
I was a medicfag too. You're on the right track for what you do for something else, but this isn't what you're thinking.
Lincoln Gonzalez
Check breath sounds. Diagnose him with pneumonia. Admit to CCU
Ryder Gutierrez
As a side note, you want to check vitals before you give nitro all willy-nilly or you'll bottom out his BP and you can kill the guy.
I'll give you vitals
Everything is normal except the tachycardia and RR being 8, slight fever of 99.8F. O2 sat is 99%.
Jaxon Taylor
Breath sounds are normal, but you hear something else... perhaps if you listen elsewhere?
Wrong diagnosis. Why admit a patient to CCU when you haven't even done a rather significant diagnostic screening?
Carson Jackson
>I'm not the greatest A-EMT
Also, my skills come to an end there. Don't even know what other drugs to give until I'm a paramedic, so transportation is the best I got. Don't know how to even read EKGs at the moment. But I'll try a bit more.
Onset? Provocation?
James Taylor
That's fine. This is a learning exercise and you get to impress your class mates if you ever come across this curveball of a diagnosis. We didn't even learn this in detail in my paramedic program. You as a medic would treat it as you did, but in reality that is wrong.
Onset: he was watching the price is right relaxing when this suddenly came on. He feared the worst and called 911. Provocation: you already know what makes it WORSE! What about better?
Benjamin Moore
Tamponade?
Grayson Brown
Perychardites
Jaxon Morris
To save the needless reply of you saying "What makes it better" I'll just tell you
He says, "Ya know, when I lean back and breath deeply it hurts a lot. But when i lean forward it makes it feel a whole lot better."
Nope. How can you confirm tamponade when you haven't even evaluated beck's triad?
Jack Stewart
The nurse sees you write that on the chart and is boggled by the spelling of the word.
Not to be a pain, but you need to go into a bit more detail as to why you think what it is.
Jason King
So it's positional. Fuck, I remember something hell's Fucking important about that in Basic.... >It's not the heart of pain is positional.
I give b/ro. But sticking around to see what others got.
Hudson Howard
How about you listen to the heart to confirm if it is the heart or not?
You auscultate the heart and you can't hear any beats. You hear this strange rubbing sound, like the sound of two balloons rubbing against eachother.
Wat do?
Dylan Parker
Ekg, symptoms and medical history suggest acute pericarditis..transtoracic Eco of the heart and blood test for the troponines to be sure..
Adam Hill
Watch Season 4, Episode 8 of House MD and $profit$
Evan Edwards
Light chest percussion to determine state of lung inflation.
If he were actually having an acute tachycardiac arrhythmic heart failure he wouldn't be talking to us, much less walking into the hospital.
Michael Morgan
Correct!
EKG was already run and showed evidence for acute pericarditis.
You do the echo and everything looks normal, but the pericardium is 4mm thick.
You run cardiac enzymes and the troponine is high... but why would you run just a troponine? He had a heart attack a few days ago and recently had a stent placed... The troponine would still be elevated. Perhaps you run a CK-MB instead? Really depends on what your hospital wants though.
BONUS POINTS! What's the actual name of this condition: acute pericarditis after an MI?
How do you treat it?
Jack Garcia
Normal.
He has no arrhythmias, only diffuse ST elevation. See for answer
Justin Clark
Dressler syndrome
Lucas Flores
Good job. Google is mighty powerful isn't it? :^)
How do you treat it?
Blake Robinson
Not being a medic, it's a way of still playing the game.
The internet suggests over the counter medicine like Ibuprofen or Naproxen. If that doesn't work a prescription for Colchicine and Corticosteroids.
Gabriel Kelly
A 21 year old white female enters your urgent care complaining of an incredibly itchy rash on her face.
She states the rash has been there for about 2 days and its getting much, much worse. The rash does not ooze, no pustules, but has a flexural and symmetric appearance. When questioning her, she has a PMH of well controlled mild intermittent asthma but other than that, everything is normal.
She states that when she goes to take a shower, it makes the rash feels much better. However, when she gets out of the shower, the cold air from her apartment makes the rash much, much worse. The rash is much worse outside in the cold fall air.
She denies any known allergies.
Her vitals are completely normal.
What is most likely the cause of this rash??
Jaxson White
Correct! You give a shit-ton of NSAIDS. You give colchicine if the event is shortly after the MI, as you do NOT give high dose NSAIDs to someone with a recent MI (within 48-72 hours).
Corticosteroids is a good treatment too.
For pain, you use codine. If they cannot take codine, too bad. The NSAIDs should treat it. Typically it resolves after one dosage of 2000mg acetaminophen.
Who would have thought that something that mimics a heart attack so well would be treated so easily?
Jacob Cooper
drug-related exanthema?
Mason Harris
Nope. But to rule that out you ask her if she has taken any medications lately. She denies taking any medications.
Think about WHEN this gets worse. Think about her past medical history.
Gabriel Harris
Ask patient if she has started eating any new foods recently or bought any new clothes/pillow cover/ bed linen/or the like.
Sounds like atopy syndrome.
Brandon Thomas
CORRECT! More specifically atopic dermatitis
Upon questioning, she states she bought this new face moisturizer and she didn't even think that that was the cause.
Treatment?
Michael Lee
Alright paramedic fags, here's one for you.
You arrive on scene to a 44 year old black male who is complaining of chest pain.
He states he was working in his yard when this just suddenly happened. He states he's dizzy and fatigued. This has never happened before. He has no past medical history and denies taking drugs or any medications.
When you get his vitals, you see he has a heart rate of 190, pulse ox is 92%, but everything else is normal.
You run an EKG and you see normal P waves are a regularly regular rhythm, although the P waves are kinda tough to spot as they seem to mash together with the T wave.
What do you think is going on? What do you do first?
Jace Cook
Identify and avoid irritants and allergens
Jack Sullivan
Pretty much.
But the patient gets upset that you won't give her anything. It's very itchy and she didn't pay a copay for some advice. What drug do you give her?
Benjamin Smith
What's the weather like? Could be heat stroke.
Josiah Collins
The riddle was already solved, my friend.
Henry Jones
There's a new one going.
Alright alright, chill cunt. She can get some topical corticosteroids.
Angel Richardson
are you preparing for the oral comity or something?
Charles Price
Could be either coronary artery disease, congestive heart failure or a heart attack. But I have no idea what to do with that EKG result :/
Blake Martin
>corticosteroids Regular steroids will do. Specifically Triamcinolone.
You can't blame her for getting upset. It's like when you go to the doctors office for a sore throat and they tell you to just wait it out. You don't go to the doctor and pay a copay to be told to just deal with it. Patients want drugs and this isn't an antibiotic so there's no harm in giving the cunt a topical steroid.
Dominic Wood
No. But lets go into more detail...
>coronary artery disease, congestive heart failure or a heart attack. You auscultate the lungs and there is no sign of consolidation or crackles. There is no edema present. The EKG shows no ST elevation, depression, inverted T waves, or significant Q waves. Only a sinus rhythm at 190 beats per minute.
No. I'm just bored while studying and this helps me stay fresh. And it's fun.
Aaron Mitchell
But if it sounds more fancy they will like it better :o
Carter Rodriguez
Globeal ST changes? Which leads? (medicgfag here).
Nathan Gray
SpO2?
William Parker
No ST changes. Normal axis. Shortened intervals due to high heart rate. All leads.
Cooper Wilson
99%, but this riddle was solved.
Wyatt Watson
do another op
Jaxson Gomez
A fib
Lucas Ross
Wrong. The P waves are normal. see Come on, guys. You all are thinking too hard. There's an old saying in medicine: "If you hear hooves, don't think about Zebras."
Sebastian Turner
Hm. My guess is the stent may have become dislodged traveling and getting stuck "further down the line". This is a good one.
Hunter Phillips
You're getting patients confused. This one is a 44 year old black male with no PMH. The first scenario was a 61 year old white male with a history of a stent 5 days ago.
I'll give you a hint. What is it called when you have a HR above 180 that is regularly regular with a normal P wave before every QRS?
Ryan Collins
1st degree heart block
Lucas Wood
Hes in tachycardia! This is serious.
Noah Young
A 1st degree heart block would not be visible with this high of a heart rate as the P wave would most likely be completely covered by the T wave. You can see the P wave in this one.
Also, as stated , the intervals are shortened not lengthened
Christian Perez
Well duh. What's the name of this kind of tachycardia?
Adrian Ross
tongue doot doot to the ass-pipe
Jace Jackson
exercise-induced tachycardia
Asher Lewis
You have made better decisions in your career and your partner reports the incident. You have gots lots of 'esplainin to do
Sebastian Davis
Yes... this is tachycardia... but what type is it? This matters because you treat this differently than regular old tachycardia.
Jordan Turner
what's his work of breathing like? what do his lungs sound like upon auscultation? Pain score, pain description, any referd pain? Blood pressure?
Tyler Murphy
I like these threads keeps me thinking
William Ross
disregard this, I'm very far behind
Hunter Hughes
Lets hang a labetalol drip and see if it does anything.
Robert Garcia
Breathing okay. Normal. No crackles, wheezes, ronchi, or evidence of consolidation. 4/10 pain. 10/10 is when he broke his pinky toe slamming it into the corner if his bed-post. The pain feels like a tightness. No referred pain. BP is normal 120/80.
Tyler Lopez
Is it supraventricular tachycardia? Does a vagal manoeuvre do anything to help?
Charles Brown
Your protocols don't allow you to carry labetalol because your medical director is a paranoid faggot.
COME ON, GUYS! Don't think so hard about this! Don't make me give you the answer.
Isaiah Hill
There we go!
You have your patient preform a vagal maneuver and it seems to slightly decrease the HR to about 160. However, once he stops, it kicks back up to the 190s.
Remember, your patient is symptomatic. While I wouldn't fault anyone for trying a vagal maneuver, there is something else I would do to treat this.
Anthony Fisher
PAC, premature atrial complexes
Daniel Reed
The P waves are normal, so this is not correct.
Cameron Barnes
is it adenosine? I'm only a second year so I'm really just stabbing in the dark
Joseph Hall
How about Edison medicine before you chemically stop the guy's heart outside of an ER setting?
Also, I'll be hard pressed to find a rig that carries adenosine.
Nicholas Kelly
I'll take a guess: Supraventricular Tachycardia? I've been sitting and looking at ACG charts to figure this out ;_;
Angel Hughes
Correct! See
Joshua Brooks
Fuck didn't see this
Tyler Watson
oh, you mean pacing right? I think intensive care paramedics carry adenosine in my country (Australia).
Jason Cruz
>pacing Not really... there is another type of thing you wanna do.
While you ponder this, another rig shows up. You happen to be manning the transport rig. They load up your patient while you stand there pondering what to do. You tell your EMT to go lights and sirens to the ER. You have 3 minutes until arrival.
Wat do?
Grayson Williams
...
Levi Mitchell
DDX
GO
Daniel Martinez
I'm such a fucking slut, I'm gonna go weep about my incurable disease, lol.
Carter Price
I'm a dumb nigger from the hood, yet I somehow became a doctor.
Luke Martin
Would Amiodarone do anything? Should probably give O2 as well. I'm really uncertain.
Adam Robinson
How about you help a brotha out and treat this nigger with 190 HR?
Owen Smith
I'm handsome and have daddy issues.
But my accent gets me all the pussy
Aiden Thomas
Amiodarone is for ventricular tachycardias, not atrial based.
Your EMT yells from the front, "HEY, DUMBASS! HOW ABOUT YOU CARDIOVERT AT 190J!" You do so and the SVT goes away! Only briefly though.
You pull into the ER and the ER staff is SO impressed with your preformance that they name you honorary doctor. The cute nurse says she'll suck your dick if you treat this guy.
You're now an ER doctor and you need to treat this guy with SVT. Wat do?
Adrian Carter
Thank you for calling Apple customer support.
Also I'm dead, lmao.
Lucas Roberts
Start your Ca+ channel blockers and beta blockers.
Titrate.
Consider shock therapy
Tyler Bennett
No green text on mobile.
38 m Wake up middle of the night violently nauseous Tremendous headache Somehow fall back asleep Wake up, head still hurts, vision is fucked up. Sporadic confusion, seeing shit, shadow masses floating through the room etc
Only major previous health issues was Venus thrombosis (sp?), years earlier, life 15 yrs.
Daniel Lewis
hypertensive crisis
Josiah Peterson
Do neurological exam. Do fundoscopic exam to rule out retinal detachment. Ask about trauma. Ask how long ago did this happen? Get CT scan. Most likely see the old stroke and pity the fool for going back to sleep and missing the 3 (or 4 hour depending on your source) hour window. Treat with admission, heparin bridge into warfarin, and rehab.
Lucas Martin
I fantasize of being pegged by House's vein cane.
James Adams
he's too far gone slap some ointment on his back, tell him to take an aspirin, and prepare the sacrificial altar
Asher Anderson
Maybe CT of the head too. Hydrocephalus or Cerebral edema
Dylan Cruz
I'm looking for adenosine.
Now what if this was afib w/ RVR? Do you still treat with adenosine?
Justin Johnson
Oh, and he could just be hung over or a diabetic. I'd ask that too.
Xavier Torres
Winrar. It was a stroke, hit both occipital lobes, got o piece of the thalamus and post medial temporal lobe. On warfarin now, headaches stopped but prescribed xanax for sleep and green to remain chill.
Took me 3 days to get to the hospital I was so confused. Therapy helped identify where the blind spots are so I kind of learned how to see around them. Doesn't help that sometimes I cannot understand what I am looking at, especially abstract or super dynamic things, like the sky, or trying to watch tv...just can't keep up anymore. I love audio books.