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Case #48 Medical Mystery?


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#1 Mike MacKinnon

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Posted 18 August 2009 - 03:06 PM

You are kicked out for a 13 y/o boy with a constellation of symptoms.

You were dispatched to a small urgent care in a rural area. The center is staffed by an NP. When you arrive the NP relates to you that the pt is a 13 y/o boy who was picked up by local EMS wand diagnosed with hypoglycemia. Upon giving dextrose the child came out of the lethargy and then multiple symptoms were noted.

He complained of sudden penetrating type lower leg pain and abdominal pain, still has some confusion even with return to normal glucose. His parents are there as well as the NP to ask questions of. They are transferring him to the main children facility in the city which is a 45 min flight away.

His vitals are: BP: 78/51 HR: 90 Sat: 98% on a NRM

Hx: none

Rx: none

Allg: none

Labs: Ca 15, others normal

What do you do?
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#2 Mattw

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Posted 18 August 2009 - 03:23 PM

I would like to know a little more history. What was the boy doing when everything started? what is his baseline? Have the parents noticed anything different recently? I would also like to do a complete head to toe exam looking for any signs of trauma or bites/stings/rashes. Any use of chemicals or other hazardous materials at the residence?
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#3 jay

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Posted 18 August 2009 - 04:10 PM

A: Seems to be maintaining from story

B: Rate and effort ok? Lung sounds ok? If so, moving on.

C: Assess color, cap refill and pulses. IV access, fluid bolus for the hypotension, 12 lead, recheck DS, Temp

Other: Good belly exam. Look at the leg with the pain, Fentanyl for pain, do they have any imaging (flat plate of belly maybe?)? any n/v?

More hx I'd like from mom and/or dad....what meds do they take? Do any grandparents live with them? If so, what meds do they take? Has he been c/o of anything lately? Recent changes in bahavior? Acting sick? Do they know anything about his recent eating and bathroom habits? If the kid is alert enough then same questions to him.

Tranport considerations: Is he alert enough to understand what is going on and be verbally reassured? If not, we'll have to deal with that before leaving (soft restraints maybe, slight sedation)

Right now I'm leaning toward an overdose
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#4 RN_mike

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Posted 19 August 2009 - 01:57 AM

First post long time reader so be gentle!!!

Looks like ABC are taken care and wee need some investigative work?

Any other labs?

What was the child doing when the symptoms came on?

Increased CA could be so many causes? As stated repeat dextrose. Any trauma to abdomen? Guarding/tenederness upon exam, bowel sounds? right/left side abdomen?

As for now treat symptoms and ask many questions of the parents.
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Michael L. Howlin RN

#5 viking563

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Posted 19 August 2009 - 02:02 AM

Few questions I have in additon to those above:
Hypoglycemia: was he unresponsive or only lethargic
Leg and ABD pain: did he have any symptoms prior the hypoglycemic issue, location of ABD pain?
Social Concerns: new group of friends, depression?
Height and Weight?

Assessment:
A: seems to be maintained
B: Rate and Depth, Pulse ox appears to be fine, Lung Sounds?
C: Pulse strength and is it regular?, skin color, cap refill time,
Head to toe looking for trauma, rashes, stings, bites,
Repeat blood sugar, if low repeat D50

Treatment:
12 Lead, 2 IV's(1 is a lock), leave the NRB as long as airway/breathing remains adequate, quick abdominal scan if available and without significant delay(ie Rad tech is on site). Fentaynl for pain, sedate and restrain as needed to transport

Still a newbie, thanks for letting me learn!
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Matt, NREMT-P

#6 mmssnb

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Posted 19 August 2009 - 06:28 AM

Do we know what his phosphorus is?
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#7 Mike MacKinnon

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Posted 19 August 2009 - 05:10 PM

Ok some answers:

[quote]What was the boy doing when everything started? what is his baseline? Have the parents noticed anything different recently? I would also like to do a complete head to toe exam looking for any signs of trauma or bites/stings/rashes. Any use of chemicals or other hazardous materials at the residence?[/quote]

Nothing special when it started but he has been nauseated for a day now, had a slowly escalating headache and mild abd pain initially.

Baseline is normal.

no trauma bites or rashes. No known chemical ingestion etc.

Resp rate and effort currently adequate.

[quote]Assess color, cap refill and pulses. IV access, fluid bolus for the hypotension, 12 lead, recheck DS, Temp[/quote]

All normal. Iv access obtained. Fluid given. 12 lead normal. temp DS normal.

[quote]Good belly exam. Look at the leg with the pain, Fentanyl for pain, do they have any imaging (flat plate of belly maybe?)? any n/v?[/quote]

diffuse adb pain. Bilateral leg pain. No imaging done.

Parents are not on any meds but beta blockers. grandparents do not live there

No unusual bathroom or eating habits recently.

Still too confused for questions.

Height and weight normal for age.

Was extremely lethargic with hypoglycemia. Still confused after correction.

Phosphorous was not done.
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#8 medic4cqb

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Posted 19 August 2009 - 06:36 PM

Ok some answers:
Nothing special when it started but he has been nauseated for a day now, had a slowly escalating headache and mild abd pain initially.

Baseline is normal.

no trauma bites or rashes. No known chemical ingestion etc.

Resp rate and effort currently adequate.
All normal. Iv access obtained. Fluid given. 12 lead normal. temp DS normal.
diffuse adb pain. Bilateral leg pain. No imaging done.

Parents are not on any meds but beta blockers. grandparents do not live there

No unusual bathroom or eating habits recently.

Still too confused for questions.

Height and weight normal for age.

Was extremely lethargic with hypoglycemia. Still confused after correction.

Phosphorous was not done.


Can we get a complete electrlyte panel? Want to know about that phos. ETOH level? Who discovered the kid, was with him last?
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Steve A., RN, CCRN, EMT-P

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#9 Mattw

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Posted 19 August 2009 - 06:51 PM

Can we get a CT of the abd? Also a blood glucose level. Any medical history for the parents/grandparents worth noting? Do we have PMS in the legs? I am starting to think about neuro and vascular systems but am not sure. I would love the thoughts of the more experienced guys and gals on here.
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#10 PhilMoney

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Posted 19 August 2009 - 09:55 PM

Ok, Here are some more questions if they havent already been asked....

- Vit A, Vit D levels?

-ACTH level?

-Homeopathic meds? New vitamin supliments?

-How low was "low" for the hypoglycemia?

-Thinking adrenal disease or thyroid with the sudden onset.....possibly Addisons or Adrenal Crisis????

-Urine output, color? Rhabdo?????

-ETOH? Urine dip for tox?
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Matt P. B.S., A.S., CCEMT-P, FP-C

#11 EDMEDIC

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Posted 20 August 2009 - 02:39 PM

HI Gang. Interesting case. I'm looking for the zebra ( there is usually at least one there). Hypercalcemia. usual causes are hyperparathyroidism and cancer. Was the leg pain there before the hypoglycemia? Any other complaints such as constipation? Are we sure there was no ingestion of non-prescription or vitamin supplements? dehydration also comes to mind as a differential. Would love to hear the answers to PhilMoney's questions!
Care /c what we know thus far.
PIV's /c NSS running, continue Hi flow O2, pain management prn, sedation if necessary for safety of flight crew and the pt, and get this lad on his way to a real hospital.

my 2 cents,
Brian
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Brian EMT-P/CC
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" you don't know what you don't know"

#12 Canis doo

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Posted 20 August 2009 - 06:47 PM

Do we have a PTH Level or CT images of spine/head/abdomen
Renal Panel
phos level
Toxicology Panel
Did child have seizures at time of symptoms
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Jason Howard LP, FP-C
You have enemies? Good. That means you've stood up for something, sometime in your life. ― Winston S. Churchill

#13 Canis doo

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Posted 20 August 2009 - 07:20 PM

Hit the wrong tab.

A few things bother me. 13yom hypotensive and not significantly or marginally tachycardic and is burning or not utilizing glucose/glycogen properly. Also he is remaining lethargic.
We know some of the major players to hypercalcemia but with out more history of events its hard to dicern.

Any significant external abnomalities i.e.: exothalmus, swollen lymphnodes, abdomial distention or masses.
Also EKG abnormailities, if any?
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Jason Howard LP, FP-C
You have enemies? Good. That means you've stood up for something, sometime in your life. ― Winston S. Churchill

#14 BackcountryMedic

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Posted 20 August 2009 - 10:30 PM

Ok, I wish I came up with this by myself, but I have to give credit to Tarascon CC pocket book and Google: Hypercalcemia is frequently the result of hyperparathyroidism. A primary hyperparathyroidism is MEN Syndrome (Multiple Endocrine Neoplasia), which has the following S/Sx: mild hypercalcemia, bone abnormalities (rare in children), hypoglycemia, headache, visual disturbances, ABD pain from peptic ulcers, diarrhea and venous thrombosis (perhaps the cause of our leg pain).

Treating MEN directly would not be possible for HEMS. Fluid boluses are a good idea (especially in this hypotensive patient).

Could be barking up the wrong tree. I'ld want a consult before I went too far with exotic treatments. So, far I agree with everyone else.
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"If everybody is thinking alike, then somebody isn't thinking" - Patton

#15 Speed

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Posted 20 August 2009 - 10:46 PM

Is the BP still low after correcting the FSBS, is it trending < or >? Sounds like an endocrine problem (Backcountry's pituitary tumor rationale) unless something weird is going on like abuse (immobilized/restrained in a closet). If it is the pituitary, and there is adrenal insufficiency you might talk about using Prednisone with one of the docs?
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Mike Williams CCEMT-P/FP-C

#16 BackcountryMedic

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Posted 21 August 2009 - 12:17 AM

Is the BP still low after correcting the FSBS, is it trending < or >? Sounds like an endocrine problem (Backcountry's pituitary tumor rationale) unless something weird is going on like abuse (immobilized/restrained in a closet). If it is the pituitary, and there is adrenal insufficiency you might talk about using Prednisone with one of the docs?


Exactly!
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"If everybody is thinking alike, then somebody isn't thinking" - Patton

#17 viking563

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Posted 21 August 2009 - 12:55 AM

Is the BP still low after correcting the FSBS,

I hate to ask but what does FSBS mean? Thanks
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Matt, NREMT-P

#18 Mike MacKinnon

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Posted 21 August 2009 - 02:29 AM

A CMP was done.

K 5.7
Na 124 mEq/L
BUN 38 mg/dL
Cr 1.1 mg/dL

rest is normal.

Cortisol lvl and ACTH & phos were not done, would you like to wait 30 minutes for them?

He was in his parents home and his mom and dad were both with him.

Can we get a complete electrlyte panel? Want to know about that phos. ETOH level? Who discovered the kid, was with him last?


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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#19 Mike MacKinnon

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Posted 21 August 2009 - 02:30 AM

No CT at this facility.

Nothing special on family Hx

PMS in legs = yes.

Can we get a CT of the abd? Also a blood glucose level. Any medical history for the parents/grandparents worth noting? Do we have PMS in the legs? I am starting to think about neuro and vascular systems but am not sure. I would love the thoughts of the more experienced guys and gals on here.


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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#20 Mike MacKinnon

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Posted 21 August 2009 - 02:32 AM

Ok



[quote]- Vit A, Vit D levels?

-ACTH level?[/quote]

Not done

[quote]-Homeopathic meds? New vitamin supliments?[/quote]

none

[quote]-How low was "low" for the hypoglycemia?[/quote]

it was 39

[quote]-Thinking adrenal disease or thyroid with the sudden onset.....possibly Addisons or Adrenal Crisis????[/quote]

Possibly, he has no Hx

[quote]-Urine output, color? Rhabdo?????[/quote]

Has not peed yet.

[quote]-ETOH? Urine dip for tox?[/quote]

No smell of etoh, no urine to dip.
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain