Presented by Ryan Phillips, MD
History of present illness:
A 76-year-old female was wheeled down to the first aid station during a 90 degree Thursday afternoon day game at Comerica Park. The patient is a member of an assisted-living home and is visiting the park as a part of “Senior Day” promotion at the assisted living home. The patient is wheeled down by one of the nurses from the home. She knows some of the patient’s medical history and knows the patient has been in good health and was her normal alert and orientated self before coming to the baseball park today. She was sitting enjoying herself for the first few innings, but the patient was thought to be napping for the past three innings. In the bottom of the 8th inning the patient was noticed to be unresponsive and not napping. The patient now is not responding to verbal stimuli, which is not normal for her.
Past medical history (as provided by the nurse): hypertension, mentally impaired
Medications: Metoprolol and hydrochlorothiazide
Past surgical history: Unknown
Social history: patient lives at a member assisted living home patient does not smoke drink or use any drugs as per the nurse with the patient
Family History: unknown
Review of systems: unobtainable
VS: T 40.5°C oral, HR 140 RR 28 BP 90/60
Gen: patient is obtunded, skin is hot and dry, pt is responding to painful stimuli but not responding to verbal
HEENT: pupils equal and reactive to light, no pallor, anicteric, there are no facial asymmetrys noted, head is normocephalic, atraumatic, nares have no discharge, oral pharynx appears dry, no erythema, + gag, neck is supple, no JVD, trachea midline
Respiratory: patient is tachypneic, lungs are clear to auscultation bilaterally with no expiratory wheeze rales or rhonchi, patient has equal chest rise
CVS: tachycardic with S1-S2 present, no murmurs or rubs
Abdomen: soft, nontender, nondistended, with positive bowel sounds, no masses, no organomegaly appreciated
Extremities: patient able to move all 4 extremities in response to pain, no asymmetric swelling or erythema patient has 1+ pulses bilateral radial and bilateral pedal, slightly decreased but symmetrical muscle tone
Skin: hot and dry, no rashes, no jaundice, no diaphoresis
Neurologically: patient responds to painful stimuli and pupils are equal and reactive to light no facial asymmetry is note, noted to move all 4 extremities, +1 DTRs, no clonus, no cogwheel rigidity
CBC Hb – 16, WBC – 12, hematocrit 51 platelets 416
Electrolytes Na – 134 K – 5.1, Cl 96, HCO3 26, BUN 62, Cr 2.1 glucose 90
AST 245 ALT 276
Chest x-ray no acute occult cardiopulmonary process
What is this patient most likely diagnosis?
A. Acute renal insufficiency
B. Heat exhaustion
C. Heat stroke
After controlling ABCs what is your next step in management with this patient?
A. CT of the head followed by lumbar puncture and initiation of steroids, ampicillin, ceftriaxone
B. Exchange transfusion and plasmapheresis
C. Oral hydration with hypotonic solutions
D. Placing an NGT and giving the patient acetaminophen 1,000mg and ibuprofen 800mg via NGT
E. Rapid cooling by removing clothing, misting the patient with water and/or immersing the patient in a tepid water bath
Despite the treatment given, the patient declines and requires rapid sequence intubation. Following successful intubation, the patient develops muscle rigidity, acidosis and her temperature is now 42°C. What medication is indicated?
E. Sodium bicarbonate
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