Quiz 26

It is an early Wednesday morning and you are an Advanced Care Paramedic working with a Primary Care Paramedic in an urban centre of approximately one million people. You are dispatched for a 23C20 Overdose in the north end of your city. Response time is five minutes with transport times ranging between 15 and 45 minutes, depending on the speciality required.

Your dispatcher informs you that you are responding to a local group home for a 59-year-old male that has suffered a possible overdose. The staff onsite state that the patient was found this morning not responding appropriately. You are dispatched to respond lights and sirens from your station and are on scene in approximately five minutes. Dispatch informs you that you have transported this patient in the past, approximately eight weeks ago, but is unable to inform you of the reason for the ambulance at that time.

On scene you are escorted by staff to the room of the 59-year-old male patient. You find the patient lying supine in bed, he appears awake and alert to you, but he is only able to recall who he is. He is unaware of the place, time or reason for your arrival. Your partner gets a set of vital signs for you while you get a history from the staff at the group home. He seems more confused to you than anything at this time.

The facility staff states that the patient has a history of hypertension, that he is a non-insulin dependent diabetic and has an extensive psychiatric history to which they do not know all the past medical problems. They state that the patient seemed “fine” and “normal” at 2100 hrs last evening when they saw him before he went to bed. They also state that the patient is on medication assist and that he has taken all his medications as prescribed and that he has no other medications found in his room (which is verified by staff and your partner who have searched the room).

On your assessment of your patient, he presents confused as noted above. The patient complains to you of general weakness with associated light-headedness and dizziness. The patient also complains of shortness of breath and has acute chest pain as well as pain radiating down his mid-back.

While communicating with him, you note obvious very slurred speech but no other neurological symptoms. The patient states he has a headache and that he is confused and having problems with his memory. Your physical assessment reveals pale, moist skin that is warm to the touch. No other physical findings noted. With ambulation, your patient has an unsteady gait and requires rest often after short walks.

Your patient’s vital signs return as:

• Heart rate of 92 bpm

• Respiratory rate of 24 per minute

• Blood pressure is 112/79

• Oxygen saturation is 90 on RA

• Blood glucose is 7.0 mmol/l

Vitals signs remain stable throughout your assessment and transport with no changes. The patient’s complaints remain the same. The core temperature en route is 38.5 C now.

Medications:

• Norvasc 5 mg 1/day

• Propranolol 10 mg 2/day

• Hydro 25 mg 1/day

• Flomax CR 0.4 mg 1/day

• Metformin 500 mg 5/day

• Fenofibrate Micro 200 mg 1/day

• Arthrotec 50 mg 2/day

• Zyprexa Zydis 10 mg 3/day

• Zyprexa Zydis 5 mg 1/day

• Trihex 2 mg 2/day

• Ranitidine 150 mg 2/day

• Ramipril 10 mg 1/day

• Ramipril 5 mg 1/day

• Docusate Sodium 100 mg 2/day

The patient has no known allergies.

1. The causes for confusion in this patient can be from:
   A) hypoxia.
   B) cerebral ischemia/CVA/TIA.
   C) cardiac ischemia.
   D) all of the above.
2. What is your primary diagnosis of this patient based on the information provided in this case?
   A) CVA.
   B) Myocardial infarction.
   C) Pneumonia—infection.
3. Based on the patient presentation, which type of centre should he be transported to?
   A) Trauma centre.
   B) Basic medical centre.
   C) Neurological site.
   D) Acute care hospital with PCI lab access.
4. You noted the Sp02 was only 90 per cent on your initial assessment with a respiratory rate of 24 per minute. What basic treatment should you perform on him on scene based on your initial examination?
   A) Oxygen.
   B) IV access.
   C) Cardiac monitor.
   D) All of the above.
5. What indication would warrant administration of oxygen to any patient?
   A) Hypoxia-hypercapnea.
   B) Tachypnea.
   C) Sp02 lower than 92 per cent in patients with S/S of respiratory distress.
   D) All of the above.
6. You decide to apply oxygen therapy to your patient as he seems to be acutely SOB with the short walk to your stretcher. What would be the appropriate therapy for this patient for oxygen administration at this time?
   A) Nasal cannula at 4 lpm.
   B) NRB at 12 lpm.
   C) NRB at 25 lpm.
   D) Nasal cannula at 6 lpm.
7. You know there are many causes of confusion or altered LOC. The acronym that you were taught was most likely AEIOU-TIPPS. The most likely differential in this patient would be:
   A) infection or diabetic shock.
   B) overdose or medication toxicity.
   C) uremia or other metabolic conditions.
   D) A and C.
   E) all of the above.
8. The patient’s condition at this time is:
   A) non-life threatening.
   B) serious or life threatening.
9. The patient’s blood sugar is:
   A) normal
   B) hyperglycemic
   C) hypoglycemic
10. By the end of your primary survey or after your rapid trauma survey you need to decide a few treatment options. You also need to make a decision on the priority transport of this patient. This patient is a “ ”, according to the normal transport criteria.
    A) load and go
    B) stay and play
11. The 12 lead and the rate of the patient’s heart rate would indicate he is in:
    A) NSR.
    B) sinus tachycardia.
    C) atrial fibrillation.
    D) SVT.
12. The heart rate from the 12 lead is within normal limits. What VS are not within the normal limits?
    A) Temperature, respirations and BP.
    B) Temperature, Sp02, respirations and BP.
    C) Temperature and Sp02.
13. The patient’s confusion does not change after you apply the oxygen therapy. This might be due to:
    A) sepsis.
    B) TIA/CVA.
    C) medication complications or interactions.
    D) all of the above.
14. The BP might be at 112/78 due to . A person would like to know what the normal range was in order to make a more informed decision, especially with treatment options. The systolic pressure in this patient would normally be 140 – 160 mmHg.
    A) medications at their therapeutic levels
    B) dehydration and decompensated shock
    C) dehydration and compensated shock
15. Being this patient is from a group home, you need additional information to make an informed treatment decision. What would be the two best differential diagnoses in this case?
    A) Impaired psychological functioning from birth complication or chronic cerebral insufficiency.
    B) Chronic mental illness.
    C) Behaviour disorder.
    D) Personality disorder.
    E) A and B.
16. The mean arterial pressure (MAP) in this patient indicates that he is:
    A) stable.
    B) unstable.
17. If you figured out the MAP you would get a mean number at around:
    A) 105.
    B) 100.
    C) 95.
    D) 90.
18. The main causes of confusion that are considered life threatening would be:
    A) dementia.
    B) delirium.
    C) insulin shock.
    D) all of the above.
19. This patient’s 12 lead shows:
    A) no acute ST changes.
    B) acute ST changes.
    C) LBBB.
    D) pericarditis.
20. The best IV therapy for this patient is:
    A) normal saline at 20 ml/kg.
    B) normal saline 500 ml bolus, then reassess the lung sounds and administer repeat boluses as required.
    C) D5W at 500 ml/hr.
    D) Ringer’s Lactate at 500 ml/hr.
21. The patient’s oxygen level remains lower than normal despite your initial oxygen therapy as well as the respiratory rate and effort remains laboured. You could administer:
    A) Ventolin 2.5 mg via neb.
    B) Atrovent 250 mcg via neb.
    C) Magnesium 2 grams IVP.
    D) A and B only.
    E) all of the above.
22. The temperature elevation, confusion, hypoxia as well as a CK result of 4000 would most likely indicate:
    A) sepsis.
    B) rhabdomyolysis.
    C) dehydration.
    D) all of the above.
23. The patient needs fluid resuscitation especially after the CK result is known with the other important findings. This is because if we don’t treat the rhabdomyolysis the patient most likely will experience acute:
    A) liver or hepatic failure.
    B) renal failure.
    C) congestive heart failure.
24. During transport the patient’s confusion does not respond. If this patient was an alcoholic you could also expect:
    A) HONK (Nonketotic hyperosmolar coma).
    B) insulin shock.
    C) delirium tremors.
    D) Wernicke-Korsakoff syndrome.
    E) C and D.
25. If you suspect alcohol withdrawal and need medications for seizure prevention or elimination you can use:
    A) Thiamine 100 mg IM or IV.
    B) Dextrose 50 g IV.
    C) Lorazepam 2 – 4 mg slow IVP or Valium 2.5 to 5 mg slow IVP or Versed 2.5 to 5.o mg slow IVP.
    D) all of the above.