Here's an interesting case from an faithful reader who wishes to remain anonymous. Some changes have been made to help preserve patient confidentiality.
This is a 60 year old male, who activated EMS for not feeling well.
The call came in from a home way out in the county, and although it was dispatched as a low acuity sick call, the responding unit ran emergency traffic to the home.
On arrival, a BLS fire unit was on scene, triaging the patient green.
Report from the firefighter EMT was as follows: Patient contacted EMS for slight shortness of breath, we have him on 15 liters O2 NRB mask, he just had a pacemaker put in three days ago.
Patient is alert and oriented x4,
VS as follows:
- O2 sat- 98% on non rebreather (RA sat was 92%)
- Pulse- around 100
Patient contact reveals the patient sitting upright in his recliner, speaking in full sentences.
He states that she is absolutely not going to the hospital no matter what!
On further questioning, patient says he has been feeling a “funny feeling” in addition to a little shortness of breath for the past hour.
- Onset of one hour
- Exertion makes it worse
- Severity is a 2/10
- Was walking to the restroom when the funny feeling started
It feels like its getting better as long as he stays still. He hasn’t taken any of his meds today.
Questioning of family members reveals that he received multiple prescriptions but hasn’t had them filled yet. He has been off all of his meds since he left the hospital two days ago.
They are unsure of all of the medications but know that they included:
Patient has no drug allergies.
- Pacemaker/ICD placed three days ago
Ate a big meal last night
Bilateral breath sounds are clear and slightly diminished.
EMS crew convinces patient to go to the local hospital 20 minutes away just to get checked out.
Patient finally agrees but is adamant about walking to the truck or else he is not going.
During the trip to the truck, patient begins to experience severe dyspnea and says that he needs to sit down.
The patient sits down on the cot for transport to the unit. Audible rales are heard when the patient begins complaining of the severe dyspnea.
In the truck, patient is attached to the cardiac monitor and a 12 lead is performed.
What is the differential diagnosis for this heart rhythm?
What do you think is going on?
How would you treat this patient?