Live from Prospect St: Dizzy at Hillcrest (part 2)

Continued from Part 1

While you chat, your partner helpfully places Ms. Smith on a nasal cannula running oxygen at 4 LPM.

You ask whether she lost consciousness when she fell, and she agrees that she may have briefly. When you ask why she fell, she states she simply tripped on the fringe of the rug. The fall was 3 hours ago, and she first vomited immediately afterwards. Until this morning, she was feeling normal, with nothing bothering her over the previous days. Her chief complaint seems to be her persistent inability to “find words,” although staff state that they called EMS mainly due to her dizziness.

When you pursue the “pressure” behind her eyes, she admits that it’s a pain of sorts, but it is obviously not too severe, and she refuses to quantify it with a number. She clarifies her dizziness by stating that although it may be worse when she stands or walks, it is continuous; she is experiencing it even as you speak.

Her pupils are equal, somewhat small, and react slightly to light. Her eyes track in all directions, with no appreciable nystagmus. When you ask her to show her teeth, she does so with no facial droop. When you ask her to hold her arms straight in front of her, palms up, with her eyes closed, she does so with no unilateral drift. She demonstrates good, equal grips, equal bilateral strength in finger-abduction and wrist flexion/extension, and equal bilateral strength in ankle dorsiflexion/plantarflexion. Her radial pulses are equal, as are her dorsalis pedis pulses, and she notes normal bilateral sensation when you pinch her hands and feet.

Throughout your conversation, she has demonstrated no slurring of speech, normal recall, and excellent orientation.

Consulting with the staff, you learn that her medications include Metoprolol, Simvastatin, Metformin, Lisinopril, Colace, Aspirin, and Coumadin for a recent hip surgery. She is allergic to Penicillin. They are unsure about her baseline BP, but Ms. Smith believes it is normally “in the 140s.” Staff believe her temperature has been recently normal, although they aren’t certain.

Your partner obtains her blood glucose at 149.

The nearest ALS is 15 minutes away.

At this point, what are the leading possibilities in your differential?

With that in mind, what is this patient’s priority?

What is your transport destination?

Is any treatment needed at this time?

Should you make any calls to mobilize further resources?


  1. Continuing from my comment on the last post, I’m glad to see she has a negative (and thorough) neuro exam. It’s nice to know she attributes her fall to tripping on the rug, but I’m still going to take that one with a grain of salt. Everyone over the age of 70 attributes their fall to the rug, and even though it is often the culprit, it’s not a guarantee.

    It would be very odd to have a significant bleed whose only finding was dysnomia with clear, normal speech and a good motor exam, but it’s still #1 on my list of things to worry about. My concerns aren’t aided by the fact that she has vomited several times. In a kid that’s just what they do when they hit their heads, but it certainly isn’t normal in an adult. Of course this could all be secondary to an infection or metabolic cause, but in the prehospital setting ICH has to be forefront in my mind.

    I would specifically question the staff about her usual ability to find words, but it may be a good sign that they aren’t worried about that and this could be her baseline, even if the patient believes otherwise.

    1) Infection (they all have UTI’s, so even if she does have a brain bleed, I’ll still be half-right)
    2) Subdural hematoma (but #1 in terms of worry)
    3) Metabolic disorder ala hyponatremia or something
    4) Tumor

    At this point, for all my worries about a subdural, I would be fine with routine transport to the slightly farther hospital. I still think it’s accepted practice to obtain an ALS intercept for this scenario in my region, but I wouldn’t fret if they weren’t available in time.
    Thanks for taking the time to post this scenario; it’s a wonderful chance to exercise those mind muscles.

    • *Great* thoughts Vince; I like how your head works. I’l post the conclusion shortly, but we have a similar approach for sure.

      And I *love* “they all have UTIs” — too true. And they’re all diabetic. And about half of them probably have compression fractures…

Speak Your Mind