Altered mental status, difficulty breathing (student case)


• Scene – O2 via NRB, IV, CPAP, EKG,vitals

• En route – Vitals, CPAP, morphine 2mg x 1, morphine 1mg x2, NTG 0.8mg x1, NTG 0.4mg x1

• Hospital – CPAP


• Admitted to hospital

• Response to treatment – pt responded to O2 NRB. SATS went up to 92% – with CPAP 98%, and up. Still had some crackles but not as much. Her color improved and she said she felt better.

• Disposition – This is the second time I have taken pt to the hospital in about 4 weeks. This time it took longer for her to turn around, and she needed CPAP at hospital. Last time when we got to the hospital the pt was able to sit upright and only needed O2 via nasal cannula.

• Notes – Pt’s son states that usually the lorazepam and hydralazine works well. She is very alert for being 98 yo/elderly. We talked about her possibly needing BiPAP at home. Pt also sleeps in a hospital-type bed that can elevate her head. She had a good diet.


Mark Shelton Paramedic Woodburn Ambulance


David M. Spiro, MD, MPH Professor of Pediatrics University of Arkansas Medical Center


• Altered mental status
• Hypertension

Differential Diagnosis

• Adverse drug effect (eg, benzodiazepine)

• Stroke (CVA)

• Myocardial infarction

• Congestive heart failure

• Arrhythmia

• Hypertensive crisis

Patient Workup History

• Patient states – Pt was not really given a chance to explain what her complaint was; she could only speak in one word sentences. Pt did say that the O2 was helping and she felt better.

• Caregiver states – Pt was given ativan and hydralazine at 2200. This usually helps pt feel better, but not tonight. Paperwork did not state that pt was having any troubles during the day.

Physical exam

• EKG – tachycardia

• CBG – 217

• GCS – 3,5,6 =14. Pt had her eyes closed, but would obey commands and understood what was going on.

• Physical findings – pt had poor color, face was blue-ish and purple. HTN, tachycardia, tachypnea, lungs were with crackles, diminished volume.

Suggested References

Altered mental status


• Gender: Female

• Age: 98 years

• Height: Not Available Vitals

• Temperature: Not Available

• Blood Pressure: 240140/140

• Heart Rate: 119

• Respiratory Rate: 30+

• Pulse Oximetry: 82% RA

Signs and Symptoms

Difficulty breathing; crackles; bluish skin.

History Medical

• PMH: A-Fib, TIA, Cerebrovascular disease.

• Allergies: PCN, erythromycin, procaine, sulfa

• Dispatch info: Difficulty breathing


• Lives at a care facility; family lives close by and sees her numerous times a week.


• Glucosamine, Ativan, Plavix, Diovan, hydralazine, melatonin, Tylenol

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