116 Montague St — shortness of breath

Location: Bravo Post

Time: 14:15 Tuesday

Conditions: Cloudy and warm

Equipment: fully stocked

 

Dispatch

The radio crackles… (click for audio)

[Ambulance 61, respond priority 1 to 116 Montague St. for shortness of breath. That's A61 to 1-1-6 Montague, cross of Madison Ave, for the conscious and breathing adult female with shortness of breath. Response is with Engine 2. Time out 14:16. A61?]

Click to expand

 

Response

You respond with lights and sirens. Engine 2 calls itself on scene over the fire radio, and less than a minute later, you pull up — a 5 minute response time. You see an average two-story residential house with five stairs.

Scenarioville Engine 2 is parked at the curb, as is a Scenarioville police cruiser. You grab the airway and first-in bags while your partner Steve takes the portable radio and stairchair. The house is a duplex, so you enter the open door and climb another twelve tightly-winding stairs to reach the second floor. It’s a nicely kept home, and you pass through the kitchen to enter the living room.

 

Scene

The room is crowded with three firefighters, a police officer, and a middle-aged woman milling around. In the middle of it all is a well-dressed elderly-looking female seated upright in an easy chair.

A firefighter waves at the seated woman and tells you, “This is Jocelyne Maynor, trouble breathing for the past couple days.”

 

Initial Assessment

You approach. “Hi! Ms. Maynor?

She looks at you immediately and responds with a strong, friendly voice, “Hi.” She appears to be alert, calm, and in no apparent distress. She is skinny and her skin is slightly pale overall. There is no obvious respiratory distress.

“I’m Sam. What’s going on?” You kneel beside her and touch her left wrist. She is warm and dry, with a strong, regular radial pulse, unremarkable in rate.

“I’ve been having trouble breathing.”

 

 


 

 

“You’re having trouble breathing right now?”

“Yes.”

“What’s it feel like?”

“Just… I’m having trouble getting enough air.”

“How long’s that been going on?”

“I think it started Saturday… but I really noticed mostly on Sunday… then it’s been getting worse since then. I called my doctor yesterday, and he said if it got any worse, I should go to the hospital.”

“Is this totally new, or do you feel this way often?”

“Sometimes I get short of breath when I’m walking around, but just for a moment, and when I sit down I feel better.”

Looking over to your partner Steve, who’s loitering around and looking at the framed photos, you ask — “Could you grab some vitals?” He digs the blood pressure cuff from the first-in bag and moves to Ms. Maynor’s other side. You turn your attention back to her.

“How are you feeling otherwise?”

“Okay.”

“No pain?”

“No.”

“How’s your chest feel?

“Fine.”

“Any fever or chills?”

“Not really. But my daughter took my temperature yesterday, and it was 100.”

The other woman in the room — presumably her daughter — interjects. “100.2.”

“Do you feel nauseous? Like you want to vomit?”

“No.”

“Have you been feeling weak?”

“Maybe a little. I usually walk with the walker, but I’ve been awfully tired lately, so I’ve mostly been resting.”

“Have you been coughing?”

“Well…” Her daughter says: “She’s been coughing for days now. All night too. She sounds awful. ”

You look back to Ms. Maynor, who grudgingly seems to endorse this.

“Are you bringing anything up?”

“What?”

“When you cough, are you coughing up any phlegm or anything?”

“Oh, yes.”

“What color is it?”

“A little yellow.”

“Been eating and drinking?”

“Some.”

“Any other recent issues?”

“No, I’ve been feeling well.”

Using your stethoscope, you auscultate her chest, asking her to breathe deeply. It sounds generally clear, somewhat dim, with some coarse, intermittent crackling sounds in the middle of the right side. After her third deep breath, she breaks out into a brief fit of coughing. Nothing notable comes up.

Steve hands you an index card with vital signs scribbled. As you take it, you’re already relaxed; he usually mentions them out loud if they’re worth remarking upon.

HR: 88

BP: 112/50

RR: 22

“What kind of medical history do you have?” you ask.

“I had a heart attack five years ago… high blood pressure… arthritis… two fused discs in my back… cataracts…” She trails off.

“What medications are you taking?”

Her daughter brings you a scrap of paper with a carefully handwritten list in beautiful cursive:

lisinopril

metoprolol

aspirin

atorvastatin

tylenol

“What hospital do you usually go to?” you ask.

“Memorial.”

“When’s the last time you were there?”

“Oh, over a year, I think.”

 

 


 

 

“Okay,” you tell her, “shall we bring you over and get you checked out?”

“Yes, I think that would be a good idea,” she answers. “What do you think is wrong?”

Steve starts to open his mouth, but immediately clamps it shut as you shoot him a dirty look; he has a bad habit of running off his mouth.

“Well, I don’t know. You’re going to need to be seen by a doctor, and they’ll do some tests. Could be some sort of pneumonia, could be something else.”

You unfold the stair-chair and situate it alongside her. “If we give you some help, do you think you can move yourself over to here?”

“Oh, sure.” You take her by both hands and assist her to stand and reseat herself onto the stair-chair, then buckle her in snugly.

“Anybody else coming?”

Her daughter answers, “I’ll take my car and meet you there. Memorial, right?”

“Yep.” Together you carry her down the winding stairs, taking special care to ensure you don’t all trip and die in a twitching pile. Scenarioville FD carries out your bags and arranges your stretcher outside; you park the chair alongside and scoop Ms. Maynor over with an extremity lift. Soon you’re rolling down the road.

You attach a nasal cannula to the on-board O2 and poke it into her nose, running 2 liters per minute. “I’m going to give you a little bit of oxygen, okay?” She nods. “Do you have any allergies to anything?”

“Not that I know of.”

Plopping yourself into the tech seat, you unhook the radio. “Say, how old are you?”

“72.”

“No way!” You dial up Memorial Hospital’s notification channel and hail them. When they acknowledge, you give this notification (click for audio):

[Good afternoon, Memorial; this is Scenarioville Ambulance 61. We're about five minutes from you with a 72 year-old female, coming from home, complaining of shortness of breath and a productive cough for the past few days. No distress, no chest pain, vitals are unremarkable, and she's otherwise doing well. We'll see you shortly; any questions?]

“No questions,” they reply. “See you on arrival. Memorial out.”

You pull in, having jotted down a quick list of her meds and history for your paperwork later. After you slide her into a bed in the ED, you make this report to the receiving RN (click for audio):

[Hi! This is Ms. Maynor, she's 72, coming from home. On Sunday she started to have some trouble breathing, just feeling like she's not really getting enough air. She's been feeling a little weaker than usual, so she hasn't been doing much walking, and she's had a decent cough since then, bringing up some yellow sputum. Talked to her doctor, he said to come in if it didn't improve. Little bit of ronchi in the mid right. Some cardiac history, had an MI a number of years ago, but no pain or discomfort, nausea, dizziness, etc. Doing okay, just looking for an eval. We've got her on a couple liters for chicken soup. Here's a list of her meds, mostly cardiac stuff.]

She thanks you and starts helping Ms. Maynor undress. You pull a blanket from the warmer and throw it over her, then shake her hand and wish her luck. Outside, Steve has cleaned and made up the stretcher, and you hop back into the truck and clear out; dispatch asks you to post at Charlie. You tap away at your computer and complete your documentation on the way.

 

Discussion

Diagnosis: pneumonia

This was a typical presentation for a routine, uncomplicated pneumonia. Although in elderly patients with comorbidities, pneumonia can sometimes lead to respiratory failure or sepsis, in this case there was little reason for alarm.

Dyspnea should always put cardiac causes on your differential, but there were no high-risk findings here except for the prior history of MI. Low-priority transport to the requested hospital is appropriate for further workup and probable antibiotic therapy.

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