Case 14: Heart-Felt Condolences

UPDATED: 4/3/2008 - Patient Follow-Up Posted.  CLICK HERE FOR THE ANSWER

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EKG Case Presentation:
Your morning unit inspection is interrupted by the pager alerting Medic1 to the scene of a 41-year-old female with an altered level of consciousness. You arrive to find a female lying supine on a bed. According to her husband, she has been minimally responsive since the early morning after failing to wake up. The husband called 9-1-1 and continued to monitor his wife until you arrived.

Initial Assessment:
The patient has an open airway and does not have labored breathing. The skin is warm and not diaphoretic. There is no evidence of trauma. A quick neurological exam reveals a Glasgow Coma Scale of 9 based on spontaneous eye opening, withdrawal to pain, and no verbal response. You record the following vital signs:

HR 57
RR 24
BP 160/100
SpO2 97%

The husband tells you that she only complained of a headache the night before, for which she took 1g of acetaminophen and went to bed. He denies that she has any recent history of illness, fever or trauma. A quick blood glucose test reveals 96 mg/dL of glucose.

Past Medical History: 
None

Allergies: 
None

Meds (generic names): 
None


Pupils are equal but slowly reactive. There is no evidence of track marks suggestive of drug abuse, or any history of alcohol or drug intake. The following EKG is obtained:

Initial EKG (click for larger image):

 

This is the EKG that you are given. The computed interpretation is not available.

Routine EKG Interpretation: Rate & Rhythm P-wave PR interval QRS interval QRS complex & mean axis ST segment T wave U wave QT interval

As the patient is moved to the stretcher, you note the patient’s reaction to pain upon eliciting flexion of the neck and some resistance and rigidity. Nonetheless, you move the patient to the stretcher. You start an IV along with supplemental oxygen and the EKG monitor. Medical command is contacted and the EKG is faxed for review.


Case 14 Discussion Questions: 

• Why would a patient with a diminished level of consciousness present with neck rigidity?
• What could be a probable differential diagnosis for this patient?
  

UPDATED: 4/3/2008 - Patient Follow-Up Posted.  CLICK HERE FOR THE ANSWER