Hello boys and girls

[Guest guest]

Hi, boys and girls. Uncle Gene has another puzzler for you. Can you say

PUZZLER? I thought you could!

Now, for the winners, The Inn At Ladonia is booked solid until the 2012

elections, since with the economic downturn the Captains of Industry lack the

bucks

to stay at the Ritz-Carlton and would be too embarrassed to spend the money

to stay there even if they had it. So they are visiting The Inn and taking in

the local flavor, including the fumes from the hog rendering plant, which is

the pride of Ladonia.

However, I do have a little rent house in Honey Grove, TX, just 10 miles

north, that you can occupy for a week. At one time the next door neighbor had

a

huge marijuana plant growing just across the fence, but I make no warranties

about that. If you win, you're on your own. Points of interest are the

State Prison in Bonham, and the.........Well, I'll get back to you on the rest

of

them.

Now, here's the scenario.

You and your partner respond to a call for an " unknown emergency " at a

residence in one of the very upscale and saddiddy neighborhoods of your town.

Dispatch says that they are having trouble understanding the caller, since she

does not speak English well, and they are attempting to get Language Line up and

will give you more information as they get it.

Before receiving any more information you arrive at the address on Orchid

Lane. It's a very large and expensive house, and there are a couple of

Mercedes

cars in the drive. The cops are also there, and they knock on the door.

It opens and a very concerned young lady opens it and says that her aunt is

having a hard time breathing and experiencing chest pain.

You enter and find an elderly Asian woman lying on a very expensive sofa in

the opulent living room. The young lady introduces herself as the niece of

the elderly lady, and she speaks excellent English. She eexplains that her

aunt just arrived from Taiwan this morning after an 18 hour flight, and had gone

to bed to rest, but woke with chest pain, difficulty breathing, sweating, and

nausea. Her mother, who speaks little English, has called 911 and also

called her at her job at Bank of America in the loan department, and she

immediately came home.

As you begin your examination of the woman, you find the following:

Pulse 38 and irregular

BP 82/54

Respirations 30 and clear, but patient seems to be very apprehensive

Temperature 97.4

PaO2 96%

Obvious increased salivation

As you question your patient through her niece, you find that she had

celebrated her 77th birthday in Taiwan, just before leaving. There was a large

birthday party with many relatives and friends, and a large dinner of regional

dishes and delicacies just before she left for the US to spend a month with her

sister.

Since chest pain is reported, you hook your patient up to the monitor and see

what appears to be a Mobitz II 2:1 AV block, with an atrial rate of about 80

and a ventricular rate of about 40.

Your patient denies that she takes any medications. She maintains that she

has been in excellent health all her life and only became sick during the

plane ride. She says that she blames her illness on the " bad air " in the

plane.

You and your partner decide to do a 12-lead and find that she has a Mobitz II

2:1 AV block, a PR interval of 220 ms, a rate of 40, and tall, peaked T-waves

in Leads V1, V2, V3, and V4, which are actually taller than the preceding QRS

complexes. They look just like church steeples.

What additional questions would you ask?

What interventions should you consider?

Although you do not have access to laboratory tests in the field, your

partner, who has spent a lot of time in Asia in the military, says he thinks he

knows what might be the cause of this patient's condition.

What does he think the cause might be?

GG

**************

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