Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 I will note that the cause of this child's seizure is nowhere in the link. Regards, Alyssa Woods, NREMT-B > for those interested, the answer to question 7 reads thus: > > Patients with hyponatremic seizures tend to have lower temperatures than > patients with seizures due to other causes. One of the most common causes > of hyponatremic seizures is excess intake of free water. This may be due to > improper formula preparation. Farrar H et al. (Hyponatremia as the cause of > seizures in infants: a retrospective analysis of incidence, severity, and > clinical predictors. Ann Emerg Med, 1995, 26:42-48) found the following > results: 47 patients less than 6 months of age were enrolled. Median seizure > duration was longer ( 30 minutes versus 17 minutes, p=0.007) in patients with > hyponatremia, with a greater incidence of status epilepticus ( 73% versus > 36%, p=0.02) Emergency intubation was performed more often in hyponatremic > patients than in normonatremic patients ( p=0.009). Median temperature was > lower in hyponatremic infants (35.5 degrees Celsius versus 37.2 degrees > Celsius, p=0.0001) Temperature less than 36.5 degrees C was the best predictor > of hyponatremic seizures. > > note that while hyponatremia and hypothermia were linked, the patients were > less than 6 months of age, and still being bottle fed. > > I will agree that in *infants,* hyponatremia and hypothermia are more > likely, and that there is a *small* chance that a 5yo kid might have managed to > suck down enough cold water from a garden hose to cause problems, but in > an acute situation, the kid would have to drink several *gallons* over the > space of an hour or so for this to happen. > > ck > > > In a message dated 07/12/11 20:33:25 Central Daylight Time, > jeremydriver@... writes: > > I found this artical while researching this: > http://www.acep.org/content.aspx?id=31418 > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 By which you mean metastatic cancer? No, but you're the closest one so far. You're thinking along the right lines -- chronic, medical, and focal. Alyssa Woods, NREMT-B (21) 842-6428 > Could be mets ca? Just a thought.. > > Excuse any errors. > Sent from my iPhone > > > > > No pets. No cat scratches. Pt is pristine except for one swollen lymph node and one minor abrasion on her chin. > > > > Alyssa Woods, NREMT-B > > > > > > Sent from the itty bitty keyboard on my iPhone > > > > > > > > > Cat-scratch encephalopathy? > > > > > > Sent from my iPhone > > > > > > > > > > > > Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > > > > > > -Brad > > > > > > Sent from my iPhone > > > > > > > > > > > > > High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > > > > > > > > Alyssa Woods, NREMT-B > > > > > > > > > > > > > > > > > > > >> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? > > > >> > > > >> Sent from my iPhone > > > >> > > > >> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@...> wrote: > > > >> > > > >> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. > > > >> > > > >> Alyssa Woods, NREMT-B > > > >> > > > >> > > > >> > > > >> > > > >> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. > > > >> > > > >> Henry > > > >> Mystery Diagnosis > > > >> > > > >> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. > > > >> > > > >> What's your treatment and what's happening to her? > > > >> > > > >> Alyssa Woods, NREMT-B > > > >> > > > >> > > > >> ---------------------------------------------------------- > > > >> > > > >> No virus found in this incoming message. > > > >> Checked by AVG - www.avg.com > > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > > >> > > > >> ---------- > > > >> > > > >> No virus found in this outgoing message. > > > >> Checked by AVG - www.avg.com > > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > > >> > > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 I'd like a 12-lead please. And my nearest CT was 40 min away? -Brad Sent from my iPhone > By which you mean metastatic cancer? No, but you're the closest one so far. You're thinking along the right lines -- chronic, medical, and focal. > > > Alyssa Woods, NREMT-B > (21) 842-6428 > > > > >> Could be mets ca? Just a thought.. >> >> Excuse any errors. >> Sent from my iPhone >> >> >> >>> No pets. No cat scratches. Pt is pristine except for one swollen lymph node and one minor abrasion on her chin. >>> >>> Alyssa Woods, NREMT-B >>> >>> >>> Sent from the itty bitty keyboard on my iPhone >>> >>> >>> >>>> Cat-scratch encephalopathy? >>>> >>>> Sent from my iPhone >>>> >>>> >>>> >>>> Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? >>>> >>>> -Brad >>>> >>>> Sent from my iPhone >>>> >>>> >>>> >>>>> High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. >>>>> >>>>> Alyssa Woods, NREMT-B >>>>> >>>>> >>>>> >>>>> >>>>>> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? >>>>>> >>>>>> Sent from my iPhone >>>>>> >>>>>> >>>>>> >>>>>> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. >>>>>> >>>>>> Alyssa Woods, NREMT-B >>>>>> >>>>>> >>>>>> >>>>>> >>>>>> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. >>>>>> >>>>>> Henry >>>>>> Mystery Diagnosis >>>>>> >>>>>> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. >>>>>> >>>>>> What's your treatment and what's happening to her? >>>>>> >>>>>> Alyssa Woods, NREMT-B >>>>>> >>>>>> >>>>>> ---------------------------------------------------------- >>>>>> >>>>>> No virus found in this incoming message. >>>>>> Checked by AVG - www.avg.com >>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 >>>>>> >>>>>> ---------- >>>>>> >>>>>> No virus found in this outgoing message. >>>>>> Checked by AVG - www.avg.com >>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 >>>>>> >>>>>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 I'd like a 12-lead please. And my nearest CT was 40 min away? -Brad Sent from my iPhone > By which you mean metastatic cancer? No, but you're the closest one so far. You're thinking along the right lines -- chronic, medical, and focal. > > > Alyssa Woods, NREMT-B > (21) 842-6428 > > > > >> Could be mets ca? Just a thought.. >> >> Excuse any errors. >> Sent from my iPhone >> >> >> >>> No pets. No cat scratches. Pt is pristine except for one swollen lymph node and one minor abrasion on her chin. >>> >>> Alyssa Woods, NREMT-B >>> >>> >>> Sent from the itty bitty keyboard on my iPhone >>> >>> >>> >>>> Cat-scratch encephalopathy? >>>> >>>> Sent from my iPhone >>>> >>>> >>>> >>>> Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? >>>> >>>> -Brad >>>> >>>> Sent from my iPhone >>>> >>>> >>>> >>>>> High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. >>>>> >>>>> Alyssa Woods, NREMT-B >>>>> >>>>> >>>>> >>>>> >>>>>> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? >>>>>> >>>>>> Sent from my iPhone >>>>>> >>>>>> >>>>>> >>>>>> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. >>>>>> >>>>>> Alyssa Woods, NREMT-B >>>>>> >>>>>> >>>>>> >>>>>> >>>>>> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. >>>>>> >>>>>> Henry >>>>>> Mystery Diagnosis >>>>>> >>>>>> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. >>>>>> >>>>>> What's your treatment and what's happening to her? >>>>>> >>>>>> Alyssa Woods, NREMT-B >>>>>> >>>>>> >>>>>> ---------------------------------------------------------- >>>>>> >>>>>> No virus found in this incoming message. >>>>>> Checked by AVG - www.avg.com >>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 >>>>>> >>>>>> ---------- >>>>>> >>>>>> No virus found in this outgoing message. >>>>>> Checked by AVG - www.avg.com >>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 >>>>>> >>>>>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Well, I mentioned a space occupying lesion eons ago. Is this what we're looking at? That's one of the rule-outs, I think. Another one would be a brain abscess secondary to some occult condition (which is, in fact, also a space occupying lesion.) Whatever it is seems to be affecting the hypothalamus. Myxedema coma is not typical in children, and doesn't usually cause seizures as far as I can tell. So I'm betting on some sort of tumor or other space occupying condition in the head. GG Re: Mystery Diagnosis By which you mean metastatic cancer? No, but you're the closest one so far. You're thinking along the right lines -- chronic, medical, and focal. Alyssa Woods, NREMT-B (21) 842-6428 > Could be mets ca? Just a thought.. > > Excuse any errors. > Sent from my iPhone > > > > > No pets. No cat scratches. Pt is pristine except for one swollen lymph node and one minor abrasion on her chin. > > > > Alyssa Woods, NREMT-B > > > > > > Sent from the itty bitty keyboard on my iPhone > > > > > > > > > Cat-scratch encephalopathy? > > > > > > Sent from my iPhone > > > > > > > > > > > > Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > > > > > > -Brad > > > > > > Sent from my iPhone > > > > > > > > > > > > > High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > > > > > > > > Alyssa Woods, NREMT-B > > > > > > > > > > > > > > > > > > > >> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? > > > >> > > > >> Sent from my iPhone > > > >> > > > >> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@...> wrote: > > > >> > > > >> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. > > > >> > > > >> Alyssa Woods, NREMT-B > > > >> > > > >> > > > >> > > > >> > > > >> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. > > > >> > > > >> Henry > > > >> Mystery Diagnosis > > > >> > > > >> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. > > > >> > > > >> What's your treatment and what's happening to her? > > > >> > > > >> Alyssa Woods, NREMT-B > > > >> > > > >> > > > >> ---------------------------------------------------------- > > > >> > > > >> No virus found in this incoming message. > > > >> Checked by AVG - www.avg.com > > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > > >> > > > >> ---------- > > > >> > > > >> No virus found in this outgoing message. > > > >> Checked by AVG - www.avg.com > > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > > >> > > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Yes. Some unknown prolonged pathology that ultimately manifests with lymph node involvement, but no other outward signs. Autoimmune problem? Lupus? Rheumatoid arthritis? HIV? Infection lower extremities? Maybe something as minor as an ingrown toenail? Excuse any errors. Sent from my iPhone > By which you mean metastatic cancer? No, but you're the closest one so far. You're thinking along the right lines -- chronic, medical, and focal. > > > Alyssa Woods, NREMT-B > (21) 842-6428 > > > > >> Could be mets ca? Just a thought.. >> >> Excuse any errors. >> Sent from my iPhone >> >> >> >>> No pets. No cat scratches. Pt is pristine except for one swollen lymph node and one minor abrasion on her chin. >>> >>> Alyssa Woods, NREMT-B >>> >>> >>> Sent from the itty bitty keyboard on my iPhone >>> >>> >>> >>>> Cat-scratch encephalopathy? >>>> >>>> Sent from my iPhone >>>> >>>> >>>> >>>> Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? >>>> >>>> -Brad >>>> >>>> Sent from my iPhone >>>> >>>> >>>> >>>>> High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. >>>>> >>>>> Alyssa Woods, NREMT-B >>>>> >>>>> >>>>> >>>>> >>>>>> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? >>>>>> >>>>>> Sent from my iPhone >>>>>> >>>>>> >>>>>> >>>>>> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. >>>>>> >>>>>> Alyssa Woods, NREMT-B >>>>>> >>>>>> >>>>>> >>>>>> >>>>>> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. >>>>>> >>>>>> Henry >>>>>> Mystery Diagnosis >>>>>> >>>>>> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. >>>>>> >>>>>> What's your treatment and what's happening to her? >>>>>> >>>>>> Alyssa Woods, NREMT-B >>>>>> >>>>>> >>>>>> ---------------------------------------------------------- >>>>>> >>>>>> No virus found in this incoming message. >>>>>> Checked by AVG - www.avg.com >>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 >>>>>> >>>>>> ---------- >>>>>> >>>>>> No virus found in this outgoing message. >>>>>> Checked by AVG - www.avg.com >>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 >>>>>> >>>>>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Yes. Some unknown prolonged pathology that ultimately manifests with lymph node involvement, but no other outward signs. Autoimmune problem? Lupus? Rheumatoid arthritis? HIV? Infection lower extremities? Maybe something as minor as an ingrown toenail? Excuse any errors. Sent from my iPhone > By which you mean metastatic cancer? No, but you're the closest one so far. You're thinking along the right lines -- chronic, medical, and focal. > > > Alyssa Woods, NREMT-B > (21) 842-6428 > > > > >> Could be mets ca? Just a thought.. >> >> Excuse any errors. >> Sent from my iPhone >> >> >> >>> No pets. No cat scratches. Pt is pristine except for one swollen lymph node and one minor abrasion on her chin. >>> >>> Alyssa Woods, NREMT-B >>> >>> >>> Sent from the itty bitty keyboard on my iPhone >>> >>> >>> >>>> Cat-scratch encephalopathy? >>>> >>>> Sent from my iPhone >>>> >>>> >>>> >>>> Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? >>>> >>>> -Brad >>>> >>>> Sent from my iPhone >>>> >>>> >>>> >>>>> High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. >>>>> >>>>> Alyssa Woods, NREMT-B >>>>> >>>>> >>>>> >>>>> >>>>>> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? >>>>>> >>>>>> Sent from my iPhone >>>>>> >>>>>> >>>>>> >>>>>> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. >>>>>> >>>>>> Alyssa Woods, NREMT-B >>>>>> >>>>>> >>>>>> >>>>>> >>>>>> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. >>>>>> >>>>>> Henry >>>>>> Mystery Diagnosis >>>>>> >>>>>> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. >>>>>> >>>>>> What's your treatment and what's happening to her? >>>>>> >>>>>> Alyssa Woods, NREMT-B >>>>>> >>>>>> >>>>>> ---------------------------------------------------------- >>>>>> >>>>>> No virus found in this incoming message. >>>>>> Checked by AVG - www.avg.com >>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 >>>>>> >>>>>> ---------- >>>>>> >>>>>> No virus found in this outgoing message. >>>>>> Checked by AVG - www.avg.com >>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 >>>>>> >>>>>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Your 12-lead is sinus tach at about 150. Your closest ER has CT capabilities, but does not have a dedicated pediatric team. Your closest dedicated children's hospital is 30-40 min in the opposite direction of your closest ER. Alyssa Woods, NREMT-B > I'd like a 12-lead please. And my nearest CT was 40 min away? > > -Brad > > Sent from my iPhone > > > > > By which you mean metastatic cancer? No, but you're the closest one so far. You're thinking along the right lines -- chronic, medical, and focal. > > > > > > Alyssa Woods, NREMT-B > > (21) 842-6428 > > > > > > > > > >> Could be mets ca? Just a thought.. > >> > >> Excuse any errors. > >> Sent from my iPhone > >> > >> > >> > >>> No pets. No cat scratches. Pt is pristine except for one swollen lymph node and one minor abrasion on her chin. > >>> > >>> Alyssa Woods, NREMT-B > >>> > >>> > >>> Sent from the itty bitty keyboard on my iPhone > >>> > >>> > >>> > >>>> Cat-scratch encephalopathy? > >>>> > >>>> Sent from my iPhone > >>>> > >>>> > >>>> > >>>> Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > >>>> > >>>> -Brad > >>>> > >>>> Sent from my iPhone > >>>> > >>>> > >>>> > >>>>> High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > >>>>> > >>>>> Alyssa Woods, NREMT-B > >>>>> > >>>>> > >>>>> > >>>>> > >>>>>> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? > >>>>>> > >>>>>> Sent from my iPhone > >>>>>> > >>>>>> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@...> wrote: > >>>>>> > >>>>>> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. > >>>>>> > >>>>>> Alyssa Woods, NREMT-B > >>>>>> > >>>>>> > >>>>>> > >>>>>> > >>>>>> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. > >>>>>> > >>>>>> Henry > >>>>>> Mystery Diagnosis > >>>>>> > >>>>>> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. > >>>>>> > >>>>>> What's your treatment and what's happening to her? > >>>>>> > >>>>>> Alyssa Woods, NREMT-B > >>>>>> > >>>>>> > >>>>>> ---------------------------------------------------------- > >>>>>> > >>>>>> No virus found in this incoming message. > >>>>>> Checked by AVG - www.avg.com > >>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > >>>>>> > >>>>>> ---------- > >>>>>> > >>>>>> No virus found in this outgoing message. > >>>>>> Checked by AVG - www.avg.com > >>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > >>>>>> > >>>>>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Your 12-lead is sinus tach at about 150. Your closest ER has CT capabilities, but does not have a dedicated pediatric team. Your closest dedicated children's hospital is 30-40 min in the opposite direction of your closest ER. Alyssa Woods, NREMT-B > I'd like a 12-lead please. And my nearest CT was 40 min away? > > -Brad > > Sent from my iPhone > > > > > By which you mean metastatic cancer? No, but you're the closest one so far. You're thinking along the right lines -- chronic, medical, and focal. > > > > > > Alyssa Woods, NREMT-B > > (21) 842-6428 > > > > > > > > > >> Could be mets ca? Just a thought.. > >> > >> Excuse any errors. > >> Sent from my iPhone > >> > >> > >> > >>> No pets. No cat scratches. Pt is pristine except for one swollen lymph node and one minor abrasion on her chin. > >>> > >>> Alyssa Woods, NREMT-B > >>> > >>> > >>> Sent from the itty bitty keyboard on my iPhone > >>> > >>> > >>> > >>>> Cat-scratch encephalopathy? > >>>> > >>>> Sent from my iPhone > >>>> > >>>> > >>>> > >>>> Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > >>>> > >>>> -Brad > >>>> > >>>> Sent from my iPhone > >>>> > >>>> > >>>> > >>>>> High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > >>>>> > >>>>> Alyssa Woods, NREMT-B > >>>>> > >>>>> > >>>>> > >>>>> > >>>>>> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? > >>>>>> > >>>>>> Sent from my iPhone > >>>>>> > >>>>>> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@...> wrote: > >>>>>> > >>>>>> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. > >>>>>> > >>>>>> Alyssa Woods, NREMT-B > >>>>>> > >>>>>> > >>>>>> > >>>>>> > >>>>>> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. > >>>>>> > >>>>>> Henry > >>>>>> Mystery Diagnosis > >>>>>> > >>>>>> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. > >>>>>> > >>>>>> What's your treatment and what's happening to her? > >>>>>> > >>>>>> Alyssa Woods, NREMT-B > >>>>>> > >>>>>> > >>>>>> ---------------------------------------------------------- > >>>>>> > >>>>>> No virus found in this incoming message. > >>>>>> Checked by AVG - www.avg.com > >>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > >>>>>> > >>>>>> ---------- > >>>>>> > >>>>>> No virus found in this outgoing message. > >>>>>> Checked by AVG - www.avg.com > >>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > >>>>>> > >>>>>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Your 12-lead is sinus tach at about 150. Your closest ER has CT capabilities, but does not have a dedicated pediatric team. Your closest dedicated children's hospital is 30-40 min in the opposite direction of your closest ER. Alyssa Woods, NREMT-B > I'd like a 12-lead please. And my nearest CT was 40 min away? > > -Brad > > Sent from my iPhone > > > > > By which you mean metastatic cancer? No, but you're the closest one so far. You're thinking along the right lines -- chronic, medical, and focal. > > > > > > Alyssa Woods, NREMT-B > > (21) 842-6428 > > > > > > > > > >> Could be mets ca? Just a thought.. > >> > >> Excuse any errors. > >> Sent from my iPhone > >> > >> > >> > >>> No pets. No cat scratches. Pt is pristine except for one swollen lymph node and one minor abrasion on her chin. > >>> > >>> Alyssa Woods, NREMT-B > >>> > >>> > >>> Sent from the itty bitty keyboard on my iPhone > >>> > >>> > >>> > >>>> Cat-scratch encephalopathy? > >>>> > >>>> Sent from my iPhone > >>>> > >>>> > >>>> > >>>> Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > >>>> > >>>> -Brad > >>>> > >>>> Sent from my iPhone > >>>> > >>>> > >>>> > >>>>> High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > >>>>> > >>>>> Alyssa Woods, NREMT-B > >>>>> > >>>>> > >>>>> > >>>>> > >>>>>> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? > >>>>>> > >>>>>> Sent from my iPhone > >>>>>> > >>>>>> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@...> wrote: > >>>>>> > >>>>>> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. > >>>>>> > >>>>>> Alyssa Woods, NREMT-B > >>>>>> > >>>>>> > >>>>>> > >>>>>> > >>>>>> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. > >>>>>> > >>>>>> Henry > >>>>>> Mystery Diagnosis > >>>>>> > >>>>>> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. > >>>>>> > >>>>>> What's your treatment and what's happening to her? > >>>>>> > >>>>>> Alyssa Woods, NREMT-B > >>>>>> > >>>>>> > >>>>>> ---------------------------------------------------------- > >>>>>> > >>>>>> No virus found in this incoming message. > >>>>>> Checked by AVG - www.avg.com > >>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > >>>>>> > >>>>>> ---------- > >>>>>> > >>>>>> No virus found in this outgoing message. > >>>>>> Checked by AVG - www.avg.com > >>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > >>>>>> > >>>>>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Not a space occupying lesion; not an abscess; not myexedema coma. This isn't an issue of overstocking; it's a simple supply-and-demand. Last hint: we do something kind of similar to dialysis patients. In her, we have to undo it. Alyssa Woods, NREMT-B > Well, I mentioned a space occupying lesion eons ago. Is this what we're looking at? > > That's one of the rule-outs, I think. > > Another one would be a brain abscess secondary to some occult condition (which is, in fact, also a space occupying lesion.) > > Whatever it is seems to be affecting the hypothalamus. > > Myxedema coma is not typical in children, and doesn't usually cause seizures as far as I can tell. > > So I'm betting on some sort of tumor or other space occupying condition in the head. > > GG > > Re: Mystery Diagnosis > > By which you mean metastatic cancer? No, but you're the closest one so far. > You're thinking along the right lines -- chronic, medical, and focal. > > Alyssa Woods, NREMT-B > (21) 842-6428 > > > > > Could be mets ca? Just a thought.. > > > > Excuse any errors. > > Sent from my iPhone > > > > > > > > > No pets. No cat scratches. Pt is pristine except for one swollen lymph node > and one minor abrasion on her chin. > > > > > > Alyssa Woods, NREMT-B > > > > > > > > > Sent from the itty bitty keyboard on my iPhone > > > > > > > > > > > > > Cat-scratch encephalopathy? > > > > > > > > Sent from my iPhone > > > > > > > > > > > > > > > > Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > > > > > > > > -Brad > > > > > > > > Sent from my iPhone > > > > > > > > On Jul 12, 2011, at 11:22 AM, Alyssa Woods amwoods8644@...> wrote: > > > > > > > > > High-dose phenobarbital drip calms her seizures for the duration of the > drip only, the node is visibly swollen. You don't see or feel any other swollen > lymph nodes. No s/s of anemia. > > > > > > > > > > Alyssa Woods, NREMT-B > > > > > > > > > > > > > > > > > > > > > > > > >> Phenobarbitol drip? Look for s/s of anemia... How big is the node? > Reasesses paying attention for nodules? > > > > >> > > > > >> Sent from my iPhone > > > > >> > > > > >> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@...> > wrote: > > > > >> > > > > >> She did not ingest a plant. Benzo's and phenobarbital stop her seizures > for 30 seconds - 1 minute, paralytics for a few minutes. > > > > >> > > > > >> Alyssa Woods, NREMT-B > > > > >> > > > > >> > > > > >> > > > > >> > > > > >> Find out what plant she possibly ingested. Begin your normal treatment > for siezure until you know more. > > > > >> > > > > >> Henry > > > > >> Mystery Diagnosis > > > > >> > > > > >> You're called out to a 5 year old girl who was playing in the yard, > when she suddenly had a seizure. When you arrive on scene her parents instantly > calm down and tell you she has no history, no medications, and no known > allergies. Your patient is having a grand mal seizure which has been going on > for at least 5 minutes. > > > > >> > > > > >> What's your treatment and what's happening to her? > > > > >> > > > > >> Alyssa Woods, NREMT-B > > > > >> > > > > >> > > > > >> ---------------------------------------------------------- > > > > >> > > > > >> No virus found in this incoming message. > > > > >> Checked by AVG - www.avg.com > > > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: > 07/11/11 18:35:00 > > > > >> > > > > >> ---------- > > > > >> > > > > >> No virus found in this outgoing message. > > > > >> Checked by AVG - www.avg.com > > > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: > 07/11/11 18:35:00 > > > > >> > > > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Leukemia or sickle cell? Excuse any errors. Sent from my iPhone > Not a space occupying lesion; not an abscess; not myexedema coma. This isn't an issue of overstocking; it's a simple supply-and-demand. > > Last hint: we do something kind of similar to dialysis patients. In her, we have to undo it. > > > > Alyssa Woods, NREMT-B > > > > > > >> Well, I mentioned a space occupying lesion eons ago. Is this what we're looking at? >> >> That's one of the rule-outs, I think. >> >> Another one would be a brain abscess secondary to some occult condition (which is, in fact, also a space occupying lesion.) >> >> Whatever it is seems to be affecting the hypothalamus. >> >> Myxedema coma is not typical in children, and doesn't usually cause seizures as far as I can tell. >> >> So I'm betting on some sort of tumor or other space occupying condition in the head. >> >> GG >> >> Re: Mystery Diagnosis >> >> By which you mean metastatic cancer? No, but you're the closest one so far. >> You're thinking along the right lines -- chronic, medical, and focal. >> >> Alyssa Woods, NREMT-B >> (21) 842-6428 >> >> >> >>> Could be mets ca? Just a thought.. >>> >>> Excuse any errors. >>> Sent from my iPhone >>> >>> >>> >>>> No pets. No cat scratches. Pt is pristine except for one swollen lymph node >> and one minor abrasion on her chin. >>>> >>>> Alyssa Woods, NREMT-B >>>> >>>> >>>> Sent from the itty bitty keyboard on my iPhone >>>> >>>> >>>> >>>>> Cat-scratch encephalopathy? >>>>> >>>>> Sent from my iPhone >>>>> >>>>> >>>>> >>>>> Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? >>>>> >>>>> -Brad >>>>> >>>>> Sent from my iPhone >>>>> >>>>> >>>>> >>>>>> High-dose phenobarbital drip calms her seizures for the duration of the >> drip only, the node is visibly swollen. You don't see or feel any other swollen >> lymph nodes. No s/s of anemia. >>>>>> >>>>>> Alyssa Woods, NREMT-B >>>>>> >>>>>> >>>>>> >>>>>> >>>>>>> Phenobarbitol drip? Look for s/s of anemia... How big is the node? >> Reasesses paying attention for nodules? >>>>>>> >>>>>>> Sent from my iPhone >>>>>>> >>>>>>> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@...> >> wrote: >>>>>>> >>>>>>> She did not ingest a plant. Benzo's and phenobarbital stop her seizures >> for 30 seconds - 1 minute, paralytics for a few minutes. >>>>>>> >>>>>>> Alyssa Woods, NREMT-B >>>>>>> >>>>>>> >>>>>>> >>>>>>> >>>>>>> Find out what plant she possibly ingested. Begin your normal treatment >> for siezure until you know more. >>>>>>> >>>>>>> Henry >>>>>>> Mystery Diagnosis >>>>>>> >>>>>>> You're called out to a 5 year old girl who was playing in the yard, >> when she suddenly had a seizure. When you arrive on scene her parents instantly >> calm down and tell you she has no history, no medications, and no known >> allergies. Your patient is having a grand mal seizure which has been going on >> for at least 5 minutes. >>>>>>> >>>>>>> What's your treatment and what's happening to her? >>>>>>> >>>>>>> Alyssa Woods, NREMT-B >>>>>>> >>>>>>> >>>>>>> ---------------------------------------------------------- >>>>>>> >>>>>>> No virus found in this incoming message. >>>>>>> Checked by AVG - www.avg.com >>>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: >> 07/11/11 18:35:00 >>>>>>> >>>>>>> ---------- >>>>>>> >>>>>>> No virus found in this outgoing message. >>>>>>> Checked by AVG - www.avg.com >>>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: >> 07/11/11 18:35:00 >>>>>>> >>>>>>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 13, 2011 Report Share Posted July 13, 2011 I think she was bitten by a bat while removing a tic. This has been a tough one. I have been waiting for Mr. Gandy to pop in and say " AW thats an easy one " and give us the answer. Henry Re: Mystery Diagnosis OK, let's see if I can sum up the current findings of the last 40 odd messages. My comments are in line at >: Chief Complaint: New Onset Seizure History of Present Illness: 5 yo WF previously in good health, noted to have major convulsions after playing outside on a hot afternoon. Onset is un certain as the parents were unpacking from the recent move. The convulsions continued for at least 5 minutes, and recurred after appropriate initial treatment. Past History: no medical or surgical history, no allergies, no medications. Social history is positive for a pregnant mother who is slightly overdue, Just moved into a new house with a koi pond, but no plants besides grass, and no known history of chemical usage in the hard or pond >Is there anything interesting in the Family History Review of Systems: The node noted on the physical exam has been present for a week, and child has an appointment with her (? new) pediatrician already scheduled. Physical exam is positive for VS: Hypothermic at 95 F Rectal, o2: 90% room air RR: 8, very shallow and erratic, no gag reflex HR: 158, sinus arrhythmia, strong pulse BP: 98/56 Mental status: she is not responsive enough to answer questions or follow commands. Reaction to pain before RSI is NOT noted. HEENT: small abrasion on the chin, pupils are equal but very sluggish. mucosa is NOT pale. Gag Reflex is absent >What would be the effective Glasgow Coma Score of this patient? Neck: no nodes or obvious nuchal rigidity Chest and Abdomen findings are NOT reported. Extremities: a solid unilateral R inguinal/thigh node is noted. It is NOT a buboe. Skin: aside from the abrasion, there are no rashes or bruising noted. No evidence of arachnid bites or stings are noted. Neurologic: Babinski's reflex is normal. Deep tendon Reflexes are NOT reported. Working evaluation: Obtunded patient with ongoing seizures and ventilatory compromise, significant hypothermia. Treatment: Open Airway, apply oxygen, establish IV Access. IV ativan is given, and the seizures stop for less than one minute before tremors which progress to grand mal activity start. Core Body temp does NOT respond to environmental temperature and aggressive warming >note: WHY are you hanging around to try to warm this patient? Repeat VS: o2: 96% on 15 LPM NRB RR: 6, very shallow and erratic, no gag reflex HR: 164, sinus arrhythmia, strong pulse BP: 94/52 >At this point, more aggressive ventilatory support should be started. Question for the group: a: name *at least* two reasons for the decrease in ventilatory effort? b: name *at least* two methods for supporting ventilation? Further Treatment: The patient is set up for RSI- the seizures stop for 'a few minutes' under the influence of the paralytics. Phenobarbital is loaded, but is no more effective than Benzos at terminating the seizures, as they reported restart shortly after the loading drip is complete. >note: this is VERY unusual for seizures. question for the group: What is the next step in the treatment of the seizures *besides* transport. Active methods to support ventilation is NOT specified. Transport issues: You have one ER without so much as a dedicated pediatrician which is about 5-10 min northwest, and one which is a dedicated children's hospital 30-40 minutes in the opposite direction. The two closest flight teams are out on other calls, and consequently their ETA is worse than yours. >incidentally, this is a case where the patient needs a good EM doc, NOT your run of the mill pediatrician! I agree, there is significant internal derangement of this patient. As Ms. Wood has already noted that the diagnosis was difficult even in the ED, I doubt anyone will guess correctly at this point. What is next? ck Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 13, 2011 Report Share Posted July 13, 2011 I think she was bitten by a bat while removing a tic. This has been a tough one. I have been waiting for Mr. Gandy to pop in and say " AW thats an easy one " and give us the answer. Henry Re: Mystery Diagnosis OK, let's see if I can sum up the current findings of the last 40 odd messages. My comments are in line at >: Chief Complaint: New Onset Seizure History of Present Illness: 5 yo WF previously in good health, noted to have major convulsions after playing outside on a hot afternoon. Onset is un certain as the parents were unpacking from the recent move. The convulsions continued for at least 5 minutes, and recurred after appropriate initial treatment. Past History: no medical or surgical history, no allergies, no medications. Social history is positive for a pregnant mother who is slightly overdue, Just moved into a new house with a koi pond, but no plants besides grass, and no known history of chemical usage in the hard or pond >Is there anything interesting in the Family History Review of Systems: The node noted on the physical exam has been present for a week, and child has an appointment with her (? new) pediatrician already scheduled. Physical exam is positive for VS: Hypothermic at 95 F Rectal, o2: 90% room air RR: 8, very shallow and erratic, no gag reflex HR: 158, sinus arrhythmia, strong pulse BP: 98/56 Mental status: she is not responsive enough to answer questions or follow commands. Reaction to pain before RSI is NOT noted. HEENT: small abrasion on the chin, pupils are equal but very sluggish. mucosa is NOT pale. Gag Reflex is absent >What would be the effective Glasgow Coma Score of this patient? Neck: no nodes or obvious nuchal rigidity Chest and Abdomen findings are NOT reported. Extremities: a solid unilateral R inguinal/thigh node is noted. It is NOT a buboe. Skin: aside from the abrasion, there are no rashes or bruising noted. No evidence of arachnid bites or stings are noted. Neurologic: Babinski's reflex is normal. Deep tendon Reflexes are NOT reported. Working evaluation: Obtunded patient with ongoing seizures and ventilatory compromise, significant hypothermia. Treatment: Open Airway, apply oxygen, establish IV Access. IV ativan is given, and the seizures stop for less than one minute before tremors which progress to grand mal activity start. Core Body temp does NOT respond to environmental temperature and aggressive warming >note: WHY are you hanging around to try to warm this patient? Repeat VS: o2: 96% on 15 LPM NRB RR: 6, very shallow and erratic, no gag reflex HR: 164, sinus arrhythmia, strong pulse BP: 94/52 >At this point, more aggressive ventilatory support should be started. Question for the group: a: name *at least* two reasons for the decrease in ventilatory effort? b: name *at least* two methods for supporting ventilation? Further Treatment: The patient is set up for RSI- the seizures stop for 'a few minutes' under the influence of the paralytics. Phenobarbital is loaded, but is no more effective than Benzos at terminating the seizures, as they reported restart shortly after the loading drip is complete. >note: this is VERY unusual for seizures. question for the group: What is the next step in the treatment of the seizures *besides* transport. Active methods to support ventilation is NOT specified. Transport issues: You have one ER without so much as a dedicated pediatrician which is about 5-10 min northwest, and one which is a dedicated children's hospital 30-40 minutes in the opposite direction. The two closest flight teams are out on other calls, and consequently their ETA is worse than yours. >incidentally, this is a case where the patient needs a good EM doc, NOT your run of the mill pediatrician! I agree, there is significant internal derangement of this patient. As Ms. Wood has already noted that the diagnosis was difficult even in the ED, I doubt anyone will guess correctly at this point. What is next? ck Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 13, 2011 Report Share Posted July 13, 2011 Do we have two different things going on here? Perhaps the seizure is related to an underlying issue in her skull that was set off by the relatively minor injury that caused the scrape on the chin and an undiagnosed oncology issue that is related to the lymph node. If not, then my guess is that it was Col. Mustard in the drawing room with the monkey wrench. Great mystery diagnosis....it's been fun watching the discussions and thought processes going on. Barry Barry Sharp, MSHP, MCHES Tobacco Prevention & Control Program Coordinator Substance Abuse Services Unit Mental Health and Substance Abuse Division ________________________________ From: texasems-l [mailto:texasems-l ] On Behalf Of Henry Barber Sent: Wednesday, July 13, 2011 7:09 AM To: texasems-l Subject: Re: Mystery Diagnosis I think she was bitten by a bat while removing a tic. This has been a tough one. I have been waiting for Mr. Gandy to pop in and say " AW thats an easy one " and give us the answer. Henry Re: Mystery Diagnosis OK, let's see if I can sum up the current findings of the last 40 odd messages. My comments are in line at >: Chief Complaint: New Onset Seizure History of Present Illness: 5 yo WF previously in good health, noted to have major convulsions after playing outside on a hot afternoon. Onset is un certain as the parents were unpacking from the recent move. The convulsions continued for at least 5 minutes, and recurred after appropriate initial treatment. Past History: no medical or surgical history, no allergies, no medications. Social history is positive for a pregnant mother who is slightly overdue, Just moved into a new house with a koi pond, but no plants besides grass, and no known history of chemical usage in the hard or pond >Is there anything interesting in the Family History Review of Systems: The node noted on the physical exam has been present for a week, and child has an appointment with her (? new) pediatrician already scheduled. Physical exam is positive for VS: Hypothermic at 95 F Rectal, o2: 90% room air RR: 8, very shallow and erratic, no gag reflex HR: 158, sinus arrhythmia, strong pulse BP: 98/56 Mental status: she is not responsive enough to answer questions or follow commands. Reaction to pain before RSI is NOT noted. HEENT: small abrasion on the chin, pupils are equal but very sluggish. mucosa is NOT pale. Gag Reflex is absent >What would be the effective Glasgow Coma Score of this patient? Neck: no nodes or obvious nuchal rigidity Chest and Abdomen findings are NOT reported. Extremities: a solid unilateral R inguinal/thigh node is noted. It is NOT a buboe. Skin: aside from the abrasion, there are no rashes or bruising noted. No evidence of arachnid bites or stings are noted. Neurologic: Babinski's reflex is normal. Deep tendon Reflexes are NOT reported. Working evaluation: Obtunded patient with ongoing seizures and ventilatory compromise, significant hypothermia. Treatment: Open Airway, apply oxygen, establish IV Access. IV ativan is given, and the seizures stop for less than one minute before tremors which progress to grand mal activity start. Core Body temp does NOT respond to environmental temperature and aggressive warming >note: WHY are you hanging around to try to warm this patient? Repeat VS: o2: 96% on 15 LPM NRB RR: 6, very shallow and erratic, no gag reflex HR: 164, sinus arrhythmia, strong pulse BP: 94/52 >At this point, more aggressive ventilatory support should be started. Question for the group: a: name *at least* two reasons for the decrease in ventilatory effort? b: name *at least* two methods for supporting ventilation? Further Treatment: The patient is set up for RSI- the seizures stop for 'a few minutes' under the influence of the paralytics. Phenobarbital is loaded, but is no more effective than Benzos at terminating the seizures, as they reported restart shortly after the loading drip is complete. >note: this is VERY unusual for seizures. question for the group: What is the next step in the treatment of the seizures *besides* transport. Active methods to support ventilation is NOT specified. Transport issues: You have one ER without so much as a dedicated pediatrician which is about 5-10 min northwest, and one which is a dedicated children's hospital 30-40 minutes in the opposite direction. The two closest flight teams are out on other calls, and consequently their ETA is worse than yours. >incidentally, this is a case where the patient needs a good EM doc, NOT your run of the mill pediatrician! I agree, there is significant internal derangement of this patient. As Ms. Wood has already noted that the diagnosis was difficult even in the ED, I doubt anyone will guess correctly at this point. What is next? ck Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 13, 2011 Report Share Posted July 13, 2011 Do we have two different things going on here? Perhaps the seizure is related to an underlying issue in her skull that was set off by the relatively minor injury that caused the scrape on the chin and an undiagnosed oncology issue that is related to the lymph node. If not, then my guess is that it was Col. Mustard in the drawing room with the monkey wrench. Great mystery diagnosis....it's been fun watching the discussions and thought processes going on. Barry Barry Sharp, MSHP, MCHES Tobacco Prevention & Control Program Coordinator Substance Abuse Services Unit Mental Health and Substance Abuse Division ________________________________ From: texasems-l [mailto:texasems-l ] On Behalf Of Henry Barber Sent: Wednesday, July 13, 2011 7:09 AM To: texasems-l Subject: Re: Mystery Diagnosis I think she was bitten by a bat while removing a tic. This has been a tough one. I have been waiting for Mr. Gandy to pop in and say " AW thats an easy one " and give us the answer. Henry Re: Mystery Diagnosis OK, let's see if I can sum up the current findings of the last 40 odd messages. My comments are in line at >: Chief Complaint: New Onset Seizure History of Present Illness: 5 yo WF previously in good health, noted to have major convulsions after playing outside on a hot afternoon. Onset is un certain as the parents were unpacking from the recent move. The convulsions continued for at least 5 minutes, and recurred after appropriate initial treatment. Past History: no medical or surgical history, no allergies, no medications. Social history is positive for a pregnant mother who is slightly overdue, Just moved into a new house with a koi pond, but no plants besides grass, and no known history of chemical usage in the hard or pond >Is there anything interesting in the Family History Review of Systems: The node noted on the physical exam has been present for a week, and child has an appointment with her (? new) pediatrician already scheduled. Physical exam is positive for VS: Hypothermic at 95 F Rectal, o2: 90% room air RR: 8, very shallow and erratic, no gag reflex HR: 158, sinus arrhythmia, strong pulse BP: 98/56 Mental status: she is not responsive enough to answer questions or follow commands. Reaction to pain before RSI is NOT noted. HEENT: small abrasion on the chin, pupils are equal but very sluggish. mucosa is NOT pale. Gag Reflex is absent >What would be the effective Glasgow Coma Score of this patient? Neck: no nodes or obvious nuchal rigidity Chest and Abdomen findings are NOT reported. Extremities: a solid unilateral R inguinal/thigh node is noted. It is NOT a buboe. Skin: aside from the abrasion, there are no rashes or bruising noted. No evidence of arachnid bites or stings are noted. Neurologic: Babinski's reflex is normal. Deep tendon Reflexes are NOT reported. Working evaluation: Obtunded patient with ongoing seizures and ventilatory compromise, significant hypothermia. Treatment: Open Airway, apply oxygen, establish IV Access. IV ativan is given, and the seizures stop for less than one minute before tremors which progress to grand mal activity start. Core Body temp does NOT respond to environmental temperature and aggressive warming >note: WHY are you hanging around to try to warm this patient? Repeat VS: o2: 96% on 15 LPM NRB RR: 6, very shallow and erratic, no gag reflex HR: 164, sinus arrhythmia, strong pulse BP: 94/52 >At this point, more aggressive ventilatory support should be started. Question for the group: a: name *at least* two reasons for the decrease in ventilatory effort? b: name *at least* two methods for supporting ventilation? Further Treatment: The patient is set up for RSI- the seizures stop for 'a few minutes' under the influence of the paralytics. Phenobarbital is loaded, but is no more effective than Benzos at terminating the seizures, as they reported restart shortly after the loading drip is complete. >note: this is VERY unusual for seizures. question for the group: What is the next step in the treatment of the seizures *besides* transport. Active methods to support ventilation is NOT specified. Transport issues: You have one ER without so much as a dedicated pediatrician which is about 5-10 min northwest, and one which is a dedicated children's hospital 30-40 minutes in the opposite direction. The two closest flight teams are out on other calls, and consequently their ETA is worse than yours. >incidentally, this is a case where the patient needs a good EM doc, NOT your run of the mill pediatrician! I agree, there is significant internal derangement of this patient. As Ms. Wood has already noted that the diagnosis was difficult even in the ED, I doubt anyone will guess correctly at this point. What is next? ck Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 13, 2011 Report Share Posted July 13, 2011 No autoimmune, Lupus, Rheumatoid, HIV. No infection. No leukemia or sickle cell. Alyssa Woods, NREMT-B (21) 842-6428 > Leukemia or sickle cell? > > Excuse any errors. > Sent from my iPhone > > > > > Not a space occupying lesion; not an abscess; not myexedema coma. This isn't an issue of overstocking; it's a simple supply-and-demand. > > > > Last hint: we do something kind of similar to dialysis patients. In her, we have to undo it. > > > > > > > > Alyssa Woods, NREMT-B > > > > > > > > > > > > > >> Well, I mentioned a space occupying lesion eons ago. Is this what we're looking at? > >> > >> That's one of the rule-outs, I think. > >> > >> Another one would be a brain abscess secondary to some occult condition (which is, in fact, also a space occupying lesion.) > >> > >> Whatever it is seems to be affecting the hypothalamus. > >> > >> Myxedema coma is not typical in children, and doesn't usually cause seizures as far as I can tell. > >> > >> So I'm betting on some sort of tumor or other space occupying condition in the head. > >> > >> GG > >> > >> Re: Mystery Diagnosis > >> > >> By which you mean metastatic cancer? No, but you're the closest one so far. > >> You're thinking along the right lines -- chronic, medical, and focal. > >> > >> Alyssa Woods, NREMT-B > >> (21) 842-6428 > >> > >> > >> > >>> Could be mets ca? Just a thought.. > >>> > >>> Excuse any errors. > >>> Sent from my iPhone > >>> > >>> > >>> > >>>> No pets. No cat scratches. Pt is pristine except for one swollen lymph node > >> and one minor abrasion on her chin. > >>>> > >>>> Alyssa Woods, NREMT-B > >>>> > >>>> > >>>> Sent from the itty bitty keyboard on my iPhone > >>>> > >>>> > >>>> > >>>>> Cat-scratch encephalopathy? > >>>>> > >>>>> Sent from my iPhone > >>>>> > >>>>> > >>>>> > >>>>> Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > >>>>> > >>>>> -Brad > >>>>> > >>>>> Sent from my iPhone > >>>>> > >>>>> On Jul 12, 2011, at 11:22 AM, Alyssa Woods amwoods8644@...> wrote: > >>>>> > >>>>>> High-dose phenobarbital drip calms her seizures for the duration of the > >> drip only, the node is visibly swollen. You don't see or feel any other swollen > >> lymph nodes. No s/s of anemia. > >>>>>> > >>>>>> Alyssa Woods, NREMT-B > >>>>>> > >>>>>> > >>>>>> > >>>>>> > >>>>>>> Phenobarbitol drip? Look for s/s of anemia... How big is the node? > >> Reasesses paying attention for nodules? > >>>>>>> > >>>>>>> Sent from my iPhone > >>>>>>> > >>>>>>> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@...> > >> wrote: > >>>>>>> > >>>>>>> She did not ingest a plant. Benzo's and phenobarbital stop her seizures > >> for 30 seconds - 1 minute, paralytics for a few minutes. > >>>>>>> > >>>>>>> Alyssa Woods, NREMT-B > >>>>>>> > >>>>>>> > >>>>>>> > >>>>>>> > >>>>>>> Find out what plant she possibly ingested. Begin your normal treatment > >> for siezure until you know more. > >>>>>>> > >>>>>>> Henry > >>>>>>> Mystery Diagnosis > >>>>>>> > >>>>>>> You're called out to a 5 year old girl who was playing in the yard, > >> when she suddenly had a seizure. When you arrive on scene her parents instantly > >> calm down and tell you she has no history, no medications, and no known > >> allergies. Your patient is having a grand mal seizure which has been going on > >> for at least 5 minutes. > >>>>>>> > >>>>>>> What's your treatment and what's happening to her? > >>>>>>> > >>>>>>> Alyssa Woods, NREMT-B > >>>>>>> > >>>>>>> > >>>>>>> ---------------------------------------------------------- > >>>>>>> > >>>>>>> No virus found in this incoming message. > >>>>>>> Checked by AVG - www.avg.com > >>>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: > >> 07/11/11 18:35:00 > >>>>>>> > >>>>>>> ---------- > >>>>>>> > >>>>>>> No virus found in this outgoing message. > >>>>>>> Checked by AVG - www.avg.com > >>>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: > >> 07/11/11 18:35:00 > >>>>>>> > >>>>>>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 13, 2011 Report Share Posted July 13, 2011 No autoimmune, Lupus, Rheumatoid, HIV. No infection. No leukemia or sickle cell. Alyssa Woods, NREMT-B (21) 842-6428 > Leukemia or sickle cell? > > Excuse any errors. > Sent from my iPhone > > > > > Not a space occupying lesion; not an abscess; not myexedema coma. This isn't an issue of overstocking; it's a simple supply-and-demand. > > > > Last hint: we do something kind of similar to dialysis patients. In her, we have to undo it. > > > > > > > > Alyssa Woods, NREMT-B > > > > > > > > > > > > > >> Well, I mentioned a space occupying lesion eons ago. Is this what we're looking at? > >> > >> That's one of the rule-outs, I think. > >> > >> Another one would be a brain abscess secondary to some occult condition (which is, in fact, also a space occupying lesion.) > >> > >> Whatever it is seems to be affecting the hypothalamus. > >> > >> Myxedema coma is not typical in children, and doesn't usually cause seizures as far as I can tell. > >> > >> So I'm betting on some sort of tumor or other space occupying condition in the head. > >> > >> GG > >> > >> Re: Mystery Diagnosis > >> > >> By which you mean metastatic cancer? No, but you're the closest one so far. > >> You're thinking along the right lines -- chronic, medical, and focal. > >> > >> Alyssa Woods, NREMT-B > >> (21) 842-6428 > >> > >> > >> > >>> Could be mets ca? Just a thought.. > >>> > >>> Excuse any errors. > >>> Sent from my iPhone > >>> > >>> > >>> > >>>> No pets. No cat scratches. Pt is pristine except for one swollen lymph node > >> and one minor abrasion on her chin. > >>>> > >>>> Alyssa Woods, NREMT-B > >>>> > >>>> > >>>> Sent from the itty bitty keyboard on my iPhone > >>>> > >>>> > >>>> > >>>>> Cat-scratch encephalopathy? > >>>>> > >>>>> Sent from my iPhone > >>>>> > >>>>> > >>>>> > >>>>> Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > >>>>> > >>>>> -Brad > >>>>> > >>>>> Sent from my iPhone > >>>>> > >>>>> On Jul 12, 2011, at 11:22 AM, Alyssa Woods amwoods8644@...> wrote: > >>>>> > >>>>>> High-dose phenobarbital drip calms her seizures for the duration of the > >> drip only, the node is visibly swollen. You don't see or feel any other swollen > >> lymph nodes. No s/s of anemia. > >>>>>> > >>>>>> Alyssa Woods, NREMT-B > >>>>>> > >>>>>> > >>>>>> > >>>>>> > >>>>>>> Phenobarbitol drip? Look for s/s of anemia... How big is the node? > >> Reasesses paying attention for nodules? > >>>>>>> > >>>>>>> Sent from my iPhone > >>>>>>> > >>>>>>> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@...> > >> wrote: > >>>>>>> > >>>>>>> She did not ingest a plant. Benzo's and phenobarbital stop her seizures > >> for 30 seconds - 1 minute, paralytics for a few minutes. > >>>>>>> > >>>>>>> Alyssa Woods, NREMT-B > >>>>>>> > >>>>>>> > >>>>>>> > >>>>>>> > >>>>>>> Find out what plant she possibly ingested. Begin your normal treatment > >> for siezure until you know more. > >>>>>>> > >>>>>>> Henry > >>>>>>> Mystery Diagnosis > >>>>>>> > >>>>>>> You're called out to a 5 year old girl who was playing in the yard, > >> when she suddenly had a seizure. When you arrive on scene her parents instantly > >> calm down and tell you she has no history, no medications, and no known > >> allergies. Your patient is having a grand mal seizure which has been going on > >> for at least 5 minutes. > >>>>>>> > >>>>>>> What's your treatment and what's happening to her? > >>>>>>> > >>>>>>> Alyssa Woods, NREMT-B > >>>>>>> > >>>>>>> > >>>>>>> ---------------------------------------------------------- > >>>>>>> > >>>>>>> No virus found in this incoming message. > >>>>>>> Checked by AVG - www.avg.com > >>>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: > >> 07/11/11 18:35:00 > >>>>>>> > >>>>>>> ---------- > >>>>>>> > >>>>>>> No virus found in this outgoing message. > >>>>>>> Checked by AVG - www.avg.com > >>>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: > >> 07/11/11 18:35:00 > >>>>>>> > >>>>>>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 13, 2011 Report Share Posted July 13, 2011 I'm leaning more to high ammonia level, either due to a previous viral infection or some congenital defect. Sent from my iPhone McGee, EMT-P > No autoimmune, Lupus, Rheumatoid, HIV. > No infection. > No leukemia or sickle cell. > > Alyssa Woods, NREMT-B > (21) 842-6428 > > > > > >> Leukemia or sickle cell? >> >> Excuse any errors. >> Sent from my iPhone >> >> >> >>> Not a space occupying lesion; not an abscess; not myexedema coma. This isn't an issue of overstocking; it's a simple supply-and-demand. >>> >>> Last hint: we do something kind of similar to dialysis patients. In her, we have to undo it. >>> >>> >>> >>> Alyssa Woods, NREMT-B >>> >>> >>> >>> >>> >>> >>>> Well, I mentioned a space occupying lesion eons ago. Is this what we're looking at? >>>> >>>> That's one of the rule-outs, I think. >>>> >>>> Another one would be a brain abscess secondary to some occult condition (which is, in fact, also a space occupying lesion.) >>>> >>>> Whatever it is seems to be affecting the hypothalamus. >>>> >>>> Myxedema coma is not typical in children, and doesn't usually cause seizures as far as I can tell. >>>> >>>> So I'm betting on some sort of tumor or other space occupying condition in the head. >>>> >>>> GG >>>> >>>> Re: Mystery Diagnosis >>>> >>>> By which you mean metastatic cancer? No, but you're the closest one so far. >>>> You're thinking along the right lines -- chronic, medical, and focal. >>>> >>>> Alyssa Woods, NREMT-B >>>> (21) 842-6428 >>>> >>>> >>>> >>>>> Could be mets ca? Just a thought.. >>>>> >>>>> Excuse any errors. >>>>> Sent from my iPhone >>>>> >>>>> >>>>> >>>>>> No pets. No cat scratches. Pt is pristine except for one swollen lymph node >>>> and one minor abrasion on her chin. >>>>>> >>>>>> Alyssa Woods, NREMT-B >>>>>> >>>>>> >>>>>> Sent from the itty bitty keyboard on my iPhone >>>>>> >>>>>> >>>>>> >>>>>>> Cat-scratch encephalopathy? >>>>>>> >>>>>>> Sent from my iPhone >>>>>>> >>>>>>> >>>>>>> >>>>>>> Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? >>>>>>> >>>>>>> -Brad >>>>>>> >>>>>>> Sent from my iPhone >>>>>>> >>>>>>> On Jul 12, 2011, at 11:22 AM, Alyssa Woods amwoods8644@...> wrote: >>>>>>> >>>>>>>> High-dose phenobarbital drip calms her seizures for the duration of the >>>> drip only, the node is visibly swollen. You don't see or feel any other swollen >>>> lymph nodes. No s/s of anemia. >>>>>>>> >>>>>>>> Alyssa Woods, NREMT-B >>>>>>>> >>>>>>>> >>>>>>>> >>>>>>>> >>>>>>>>> Phenobarbitol drip? Look for s/s of anemia... How big is the node? >>>> Reasesses paying attention for nodules? >>>>>>>>> >>>>>>>>> Sent from my iPhone >>>>>>>>> >>>>>>>>> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@...> >>>> wrote: >>>>>>>>> >>>>>>>>> She did not ingest a plant. Benzo's and phenobarbital stop her seizures >>>> for 30 seconds - 1 minute, paralytics for a few minutes. >>>>>>>>> >>>>>>>>> Alyssa Woods, NREMT-B >>>>>>>>> >>>>>>>>> >>>>>>>>> >>>>>>>>> >>>>>>>>> Find out what plant she possibly ingested. Begin your normal treatment >>>> for siezure until you know more. >>>>>>>>> >>>>>>>>> Henry >>>>>>>>> Mystery Diagnosis >>>>>>>>> >>>>>>>>> You're called out to a 5 year old girl who was playing in the yard, >>>> when she suddenly had a seizure. When you arrive on scene her parents instantly >>>> calm down and tell you she has no history, no medications, and no known >>>> allergies. Your patient is having a grand mal seizure which has been going on >>>> for at least 5 minutes. >>>>>>>>> >>>>>>>>> What's your treatment and what's happening to her? >>>>>>>>> >>>>>>>>> Alyssa Woods, NREMT-B >>>>>>>>> >>>>>>>>> >>>>>>>>> ---------------------------------------------------------- >>>>>>>>> >>>>>>>>> No virus found in this incoming message. >>>>>>>>> Checked by AVG - www.avg.com >>>>>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: >>>> 07/11/11 18:35:00 >>>>>>>>> >>>>>>>>> ---------- >>>>>>>>> >>>>>>>>> No virus found in this outgoing message. >>>>>>>>> Checked by AVG - www.avg.com >>>>>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: >>>> 07/11/11 18:35:00 >>>>>>>>> >>>>>>>>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 13, 2011 Report Share Posted July 13, 2011 I'm leaning more to high ammonia level, either due to a previous viral infection or some congenital defect. Sent from my iPhone McGee, EMT-P > No autoimmune, Lupus, Rheumatoid, HIV. > No infection. > No leukemia or sickle cell. > > Alyssa Woods, NREMT-B > (21) 842-6428 > > > > > >> Leukemia or sickle cell? >> >> Excuse any errors. >> Sent from my iPhone >> >> >> >>> Not a space occupying lesion; not an abscess; not myexedema coma. This isn't an issue of overstocking; it's a simple supply-and-demand. >>> >>> Last hint: we do something kind of similar to dialysis patients. In her, we have to undo it. >>> >>> >>> >>> Alyssa Woods, NREMT-B >>> >>> >>> >>> >>> >>> >>>> Well, I mentioned a space occupying lesion eons ago. Is this what we're looking at? >>>> >>>> That's one of the rule-outs, I think. >>>> >>>> Another one would be a brain abscess secondary to some occult condition (which is, in fact, also a space occupying lesion.) >>>> >>>> Whatever it is seems to be affecting the hypothalamus. >>>> >>>> Myxedema coma is not typical in children, and doesn't usually cause seizures as far as I can tell. >>>> >>>> So I'm betting on some sort of tumor or other space occupying condition in the head. >>>> >>>> GG >>>> >>>> Re: Mystery Diagnosis >>>> >>>> By which you mean metastatic cancer? No, but you're the closest one so far. >>>> You're thinking along the right lines -- chronic, medical, and focal. >>>> >>>> Alyssa Woods, NREMT-B >>>> (21) 842-6428 >>>> >>>> >>>> >>>>> Could be mets ca? Just a thought.. >>>>> >>>>> Excuse any errors. >>>>> Sent from my iPhone >>>>> >>>>> >>>>> >>>>>> No pets. No cat scratches. Pt is pristine except for one swollen lymph node >>>> and one minor abrasion on her chin. >>>>>> >>>>>> Alyssa Woods, NREMT-B >>>>>> >>>>>> >>>>>> Sent from the itty bitty keyboard on my iPhone >>>>>> >>>>>> >>>>>> >>>>>>> Cat-scratch encephalopathy? >>>>>>> >>>>>>> Sent from my iPhone >>>>>>> >>>>>>> >>>>>>> >>>>>>> Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? >>>>>>> >>>>>>> -Brad >>>>>>> >>>>>>> Sent from my iPhone >>>>>>> >>>>>>> On Jul 12, 2011, at 11:22 AM, Alyssa Woods amwoods8644@...> wrote: >>>>>>> >>>>>>>> High-dose phenobarbital drip calms her seizures for the duration of the >>>> drip only, the node is visibly swollen. You don't see or feel any other swollen >>>> lymph nodes. No s/s of anemia. >>>>>>>> >>>>>>>> Alyssa Woods, NREMT-B >>>>>>>> >>>>>>>> >>>>>>>> >>>>>>>> >>>>>>>>> Phenobarbitol drip? Look for s/s of anemia... How big is the node? >>>> Reasesses paying attention for nodules? >>>>>>>>> >>>>>>>>> Sent from my iPhone >>>>>>>>> >>>>>>>>> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@...> >>>> wrote: >>>>>>>>> >>>>>>>>> She did not ingest a plant. Benzo's and phenobarbital stop her seizures >>>> for 30 seconds - 1 minute, paralytics for a few minutes. >>>>>>>>> >>>>>>>>> Alyssa Woods, NREMT-B >>>>>>>>> >>>>>>>>> >>>>>>>>> >>>>>>>>> >>>>>>>>> Find out what plant she possibly ingested. Begin your normal treatment >>>> for siezure until you know more. >>>>>>>>> >>>>>>>>> Henry >>>>>>>>> Mystery Diagnosis >>>>>>>>> >>>>>>>>> You're called out to a 5 year old girl who was playing in the yard, >>>> when she suddenly had a seizure. When you arrive on scene her parents instantly >>>> calm down and tell you she has no history, no medications, and no known >>>> allergies. Your patient is having a grand mal seizure which has been going on >>>> for at least 5 minutes. >>>>>>>>> >>>>>>>>> What's your treatment and what's happening to her? >>>>>>>>> >>>>>>>>> Alyssa Woods, NREMT-B >>>>>>>>> >>>>>>>>> >>>>>>>>> ---------------------------------------------------------- >>>>>>>>> >>>>>>>>> No virus found in this incoming message. >>>>>>>>> Checked by AVG - www.avg.com >>>>>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: >>>> 07/11/11 18:35:00 >>>>>>>>> >>>>>>>>> ---------- >>>>>>>>> >>>>>>>>> No virus found in this outgoing message. >>>>>>>>> Checked by AVG - www.avg.com >>>>>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: >>>> 07/11/11 18:35:00 >>>>>>>>> >>>>>>>>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 13, 2011 Report Share Posted July 13, 2011 Ok; any guesses as to what is going on in her skull? I will accept both the condition she has and what it's led to. You're going along the right track; I don't care what " Dr House " says; sometimes, it really is just a coincidence. Let's review our hints. It's not external, it's internal. The temperature is important. It's an act of God that man can fix. It's chronic, and focal. We create something kind of similar in dialysis patients; in her we must undo it. Alyssa Woods, NREMT-B > Do we have two different things going on here? Perhaps the seizure is > related to an underlying issue in her skull that was set off by the > relatively minor injury that caused the scrape on the chin and an > undiagnosed oncology issue that is related to the lymph node. > > If not, then my guess is that it was Col. Mustard in the drawing room > with the monkey wrench. > > Great mystery diagnosis....it's been fun watching the discussions and > thought processes going on. > > Barry > > Barry Sharp, MSHP, MCHES > > Tobacco Prevention & Control Program Coordinator > > Substance Abuse Services Unit > > Mental Health and Substance Abuse Division > > > > ________________________________ > > From: texasems-l [mailto:texasems-l ] On > Behalf Of Henry Barber > Sent: Wednesday, July 13, 2011 7:09 AM > To: texasems-l > Subject: Re: Mystery Diagnosis > > I think she was bitten by a bat while removing a tic. This has been a > tough one. I have been waiting for Mr. Gandy to pop in and say " AW thats > an easy one " and give us the answer. > > Henry > Re: Mystery Diagnosis > > OK, let's see if I can sum up the current findings of the last 40 odd > messages. My comments are in line at >: > > Chief Complaint: New Onset Seizure > > History of Present Illness: 5 yo WF previously in good health, noted to > have major convulsions after playing outside on a hot afternoon. Onset > is un > certain as the parents were unpacking from the recent move. The > convulsions > continued for at least 5 minutes, and recurred after appropriate initial > > treatment. > > Past History: no medical or surgical history, no allergies, no > medications. > > Social history is positive for a pregnant mother who is slightly > overdue, > Just moved into a new house with a koi pond, but no plants besides > grass, > and no known history of chemical usage in the hard or pond > > >Is there anything interesting in the Family History > > Review of Systems: The node noted on the physical exam has been present > for a week, and child has an appointment with her (? new) pediatrician > already scheduled. > > Physical exam is positive for > > VS: Hypothermic at 95 F Rectal, o2: 90% room air > RR: 8, very shallow and erratic, no gag reflex > HR: 158, sinus arrhythmia, strong pulse > BP: 98/56 > > Mental status: she is not responsive enough to answer questions or > follow > commands. Reaction to pain before RSI is NOT noted. > > HEENT: small abrasion on the chin, pupils are equal but very sluggish. > mucosa is NOT pale. Gag Reflex is absent > > >What would be the effective Glasgow Coma Score of this patient? > > Neck: no nodes or obvious nuchal rigidity > > Chest and Abdomen findings are NOT reported. > > Extremities: a solid unilateral R inguinal/thigh node is noted. It is > NOT > a buboe. > > Skin: aside from the abrasion, there are no rashes or bruising noted. No > > evidence of arachnid bites or stings are noted. > > Neurologic: Babinski's reflex is normal. Deep tendon Reflexes are NOT > reported. > > Working evaluation: Obtunded patient with ongoing seizures and > ventilatory > compromise, significant hypothermia. > > Treatment: Open Airway, apply oxygen, establish IV Access. IV ativan is > given, and the seizures stop for less than one minute before tremors > which > progress to grand mal activity start. Core Body temp does NOT respond to > > environmental temperature and aggressive warming > > >note: WHY are you hanging around to try to warm this patient? > > Repeat VS: > o2: 96% on 15 LPM NRB > RR: 6, very shallow and erratic, no gag reflex > HR: 164, sinus arrhythmia, strong pulse > BP: 94/52 > > >At this point, more aggressive ventilatory support should be started. > Question for the group: > a: name *at least* two reasons for the decrease in ventilatory effort? > b: name *at least* two methods for supporting ventilation? > > Further Treatment: The patient is set up for RSI- the seizures stop for > 'a > few minutes' under the influence of the paralytics. Phenobarbital is > loaded, but is no more effective than Benzos at terminating the > seizures, as > they reported restart shortly after the loading drip is complete. > > >note: this is VERY unusual for seizures. question for the group: What > is > the next step in the treatment of the seizures *besides* transport. > > Active methods to support ventilation is NOT specified. > > Transport issues: You have one ER without so much as a dedicated > pediatrician which is about 5-10 min northwest, and one which is a > dedicated > children's hospital 30-40 minutes in the opposite direction. The two > closest > flight teams are out on other calls, and consequently their ETA is worse > than > yours. > > >incidentally, this is a case where the patient needs a good EM doc, NOT > > your run of the mill pediatrician! > > I agree, there is significant internal derangement of this patient. As > Ms. > Wood has already noted that the diagnosis was difficult even in the ED, > I > doubt anyone will guess correctly at this point. > > What is next? > > ck > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 13, 2011 Report Share Posted July 13, 2011 Ok; any guesses as to what is going on in her skull? I will accept both the condition she has and what it's led to. You're going along the right track; I don't care what " Dr House " says; sometimes, it really is just a coincidence. Let's review our hints. It's not external, it's internal. The temperature is important. It's an act of God that man can fix. It's chronic, and focal. We create something kind of similar in dialysis patients; in her we must undo it. Alyssa Woods, NREMT-B > Do we have two different things going on here? Perhaps the seizure is > related to an underlying issue in her skull that was set off by the > relatively minor injury that caused the scrape on the chin and an > undiagnosed oncology issue that is related to the lymph node. > > If not, then my guess is that it was Col. Mustard in the drawing room > with the monkey wrench. > > Great mystery diagnosis....it's been fun watching the discussions and > thought processes going on. > > Barry > > Barry Sharp, MSHP, MCHES > > Tobacco Prevention & Control Program Coordinator > > Substance Abuse Services Unit > > Mental Health and Substance Abuse Division > > > > ________________________________ > > From: texasems-l [mailto:texasems-l ] On > Behalf Of Henry Barber > Sent: Wednesday, July 13, 2011 7:09 AM > To: texasems-l > Subject: Re: Mystery Diagnosis > > I think she was bitten by a bat while removing a tic. This has been a > tough one. I have been waiting for Mr. Gandy to pop in and say " AW thats > an easy one " and give us the answer. > > Henry > Re: Mystery Diagnosis > > OK, let's see if I can sum up the current findings of the last 40 odd > messages. My comments are in line at >: > > Chief Complaint: New Onset Seizure > > History of Present Illness: 5 yo WF previously in good health, noted to > have major convulsions after playing outside on a hot afternoon. Onset > is un > certain as the parents were unpacking from the recent move. The > convulsions > continued for at least 5 minutes, and recurred after appropriate initial > > treatment. > > Past History: no medical or surgical history, no allergies, no > medications. > > Social history is positive for a pregnant mother who is slightly > overdue, > Just moved into a new house with a koi pond, but no plants besides > grass, > and no known history of chemical usage in the hard or pond > > >Is there anything interesting in the Family History > > Review of Systems: The node noted on the physical exam has been present > for a week, and child has an appointment with her (? new) pediatrician > already scheduled. > > Physical exam is positive for > > VS: Hypothermic at 95 F Rectal, o2: 90% room air > RR: 8, very shallow and erratic, no gag reflex > HR: 158, sinus arrhythmia, strong pulse > BP: 98/56 > > Mental status: she is not responsive enough to answer questions or > follow > commands. Reaction to pain before RSI is NOT noted. > > HEENT: small abrasion on the chin, pupils are equal but very sluggish. > mucosa is NOT pale. Gag Reflex is absent > > >What would be the effective Glasgow Coma Score of this patient? > > Neck: no nodes or obvious nuchal rigidity > > Chest and Abdomen findings are NOT reported. > > Extremities: a solid unilateral R inguinal/thigh node is noted. It is > NOT > a buboe. > > Skin: aside from the abrasion, there are no rashes or bruising noted. No > > evidence of arachnid bites or stings are noted. > > Neurologic: Babinski's reflex is normal. Deep tendon Reflexes are NOT > reported. > > Working evaluation: Obtunded patient with ongoing seizures and > ventilatory > compromise, significant hypothermia. > > Treatment: Open Airway, apply oxygen, establish IV Access. IV ativan is > given, and the seizures stop for less than one minute before tremors > which > progress to grand mal activity start. Core Body temp does NOT respond to > > environmental temperature and aggressive warming > > >note: WHY are you hanging around to try to warm this patient? > > Repeat VS: > o2: 96% on 15 LPM NRB > RR: 6, very shallow and erratic, no gag reflex > HR: 164, sinus arrhythmia, strong pulse > BP: 94/52 > > >At this point, more aggressive ventilatory support should be started. > Question for the group: > a: name *at least* two reasons for the decrease in ventilatory effort? > b: name *at least* two methods for supporting ventilation? > > Further Treatment: The patient is set up for RSI- the seizures stop for > 'a > few minutes' under the influence of the paralytics. Phenobarbital is > loaded, but is no more effective than Benzos at terminating the > seizures, as > they reported restart shortly after the loading drip is complete. > > >note: this is VERY unusual for seizures. question for the group: What > is > the next step in the treatment of the seizures *besides* transport. > > Active methods to support ventilation is NOT specified. > > Transport issues: You have one ER without so much as a dedicated > pediatrician which is about 5-10 min northwest, and one which is a > dedicated > children's hospital 30-40 minutes in the opposite direction. The two > closest > flight teams are out on other calls, and consequently their ETA is worse > than > yours. > > >incidentally, this is a case where the patient needs a good EM doc, NOT > > your run of the mill pediatrician! > > I agree, there is significant internal derangement of this patient. As > Ms. > Wood has already noted that the diagnosis was difficult even in the ED, > I > doubt anyone will guess correctly at this point. > > What is next? > > ck > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 13, 2011 Report Share Posted July 13, 2011 Hypothalamus? Wes On the move from my iPhone > Ok; any guesses as to what is going on in her skull? I will accept both the condition she has and what it's led to. > > You're going along the right track; I don't care what " Dr House " says; sometimes, it really is just a coincidence. > > > Let's review our hints. > > It's not external, it's internal. > The temperature is important. > It's an act of God that man can fix. > It's chronic, and focal. > We create something kind of similar in dialysis patients; in her we must undo it. > > > Alyssa Woods, NREMT-B > > > > > > >> Do we have two different things going on here? Perhaps the seizure is >> related to an underlying issue in her skull that was set off by the >> relatively minor injury that caused the scrape on the chin and an >> undiagnosed oncology issue that is related to the lymph node. >> >> If not, then my guess is that it was Col. Mustard in the drawing room >> with the monkey wrench. >> >> Great mystery diagnosis....it's been fun watching the discussions and >> thought processes going on. >> >> Barry >> >> Barry Sharp, MSHP, MCHES >> >> Tobacco Prevention & Control Program Coordinator >> >> Substance Abuse Services Unit >> >> Mental Health and Substance Abuse Division >> >> >> >> ________________________________ >> >> From: texasems-l [mailto:texasems-l ] On >> Behalf Of Henry Barber >> Sent: Wednesday, July 13, 2011 7:09 AM >> To: texasems-l >> Subject: Re: Mystery Diagnosis >> >> I think she was bitten by a bat while removing a tic. This has been a >> tough one. I have been waiting for Mr. Gandy to pop in and say " AW thats >> an easy one " and give us the answer. >> >> Henry >> Re: Mystery Diagnosis >> >> OK, let's see if I can sum up the current findings of the last 40 odd >> messages. My comments are in line at >: >> >> Chief Complaint: New Onset Seizure >> >> History of Present Illness: 5 yo WF previously in good health, noted to >> have major convulsions after playing outside on a hot afternoon. Onset >> is un >> certain as the parents were unpacking from the recent move. The >> convulsions >> continued for at least 5 minutes, and recurred after appropriate initial >> >> treatment. >> >> Past History: no medical or surgical history, no allergies, no >> medications. >> >> Social history is positive for a pregnant mother who is slightly >> overdue, >> Just moved into a new house with a koi pond, but no plants besides >> grass, >> and no known history of chemical usage in the hard or pond >> >>> Is there anything interesting in the Family History >> >> Review of Systems: The node noted on the physical exam has been present >> for a week, and child has an appointment with her (? new) pediatrician >> already scheduled. >> >> Physical exam is positive for >> >> VS: Hypothermic at 95 F Rectal, o2: 90% room air >> RR: 8, very shallow and erratic, no gag reflex >> HR: 158, sinus arrhythmia, strong pulse >> BP: 98/56 >> >> Mental status: she is not responsive enough to answer questions or >> follow >> commands. Reaction to pain before RSI is NOT noted. >> >> HEENT: small abrasion on the chin, pupils are equal but very sluggish. >> mucosa is NOT pale. Gag Reflex is absent >> >>> What would be the effective Glasgow Coma Score of this patient? >> >> Neck: no nodes or obvious nuchal rigidity >> >> Chest and Abdomen findings are NOT reported. >> >> Extremities: a solid unilateral R inguinal/thigh node is noted. It is >> NOT >> a buboe. >> >> Skin: aside from the abrasion, there are no rashes or bruising noted. No >> >> evidence of arachnid bites or stings are noted. >> >> Neurologic: Babinski's reflex is normal. Deep tendon Reflexes are NOT >> reported. >> >> Working evaluation: Obtunded patient with ongoing seizures and >> ventilatory >> compromise, significant hypothermia. >> >> Treatment: Open Airway, apply oxygen, establish IV Access. IV ativan is >> given, and the seizures stop for less than one minute before tremors >> which >> progress to grand mal activity start. Core Body temp does NOT respond to >> >> environmental temperature and aggressive warming >> >>> note: WHY are you hanging around to try to warm this patient? >> >> Repeat VS: >> o2: 96% on 15 LPM NRB >> RR: 6, very shallow and erratic, no gag reflex >> HR: 164, sinus arrhythmia, strong pulse >> BP: 94/52 >> >>> At this point, more aggressive ventilatory support should be started. >> Question for the group: >> a: name *at least* two reasons for the decrease in ventilatory effort? >> b: name *at least* two methods for supporting ventilation? >> >> Further Treatment: The patient is set up for RSI- the seizures stop for >> 'a >> few minutes' under the influence of the paralytics. Phenobarbital is >> loaded, but is no more effective than Benzos at terminating the >> seizures, as >> they reported restart shortly after the loading drip is complete. >> >>> note: this is VERY unusual for seizures. question for the group: What >> is >> the next step in the treatment of the seizures *besides* transport. >> >> Active methods to support ventilation is NOT specified. >> >> Transport issues: You have one ER without so much as a dedicated >> pediatrician which is about 5-10 min northwest, and one which is a >> dedicated >> children's hospital 30-40 minutes in the opposite direction. The two >> closest >> flight teams are out on other calls, and consequently their ETA is worse >> than >> yours. >> >>> incidentally, this is a case where the patient needs a good EM doc, NOT >> >> your run of the mill pediatrician! >> >> I agree, there is significant internal derangement of this patient. As >> Ms. >> Wood has already noted that the diagnosis was difficult even in the ED, >> I >> doubt anyone will guess correctly at this point. >> >> What is next? >> >> ck >> >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 13, 2011 Report Share Posted July 13, 2011 No abnormal ammonia levels. Alyssa Woods, NREMT-B > I'm leaning more to high ammonia level, either due to a previous viral infection or some congenital defect. > > Sent from my iPhone > McGee, EMT-P > > > > > No autoimmune, Lupus, Rheumatoid, HIV. > > No infection. > > No leukemia or sickle cell. > > > > Alyssa Woods, NREMT-B > > (21) 842-6428 > > > > > > > > > > > >> Leukemia or sickle cell? > >> > >> Excuse any errors. > >> Sent from my iPhone > >> > >> > >> > >>> Not a space occupying lesion; not an abscess; not myexedema coma. This isn't an issue of overstocking; it's a simple supply-and-demand. > >>> > >>> Last hint: we do something kind of similar to dialysis patients. In her, we have to undo it. > >>> > >>> > >>> > >>> Alyssa Woods, NREMT-B > >>> > >>> > >>> > >>> > >>> > >>> > >>>> Well, I mentioned a space occupying lesion eons ago. Is this what we're looking at? > >>>> > >>>> That's one of the rule-outs, I think. > >>>> > >>>> Another one would be a brain abscess secondary to some occult condition (which is, in fact, also a space occupying lesion.) > >>>> > >>>> Whatever it is seems to be affecting the hypothalamus. > >>>> > >>>> Myxedema coma is not typical in children, and doesn't usually cause seizures as far as I can tell. > >>>> > >>>> So I'm betting on some sort of tumor or other space occupying condition in the head. > >>>> > >>>> GG > >>>> > >>>> Re: Mystery Diagnosis > >>>> > >>>> By which you mean metastatic cancer? No, but you're the closest one so far. > >>>> You're thinking along the right lines -- chronic, medical, and focal. > >>>> > >>>> Alyssa Woods, NREMT-B > >>>> (21) 842-6428 > >>>> > >>>> > >>>> > >>>>> Could be mets ca? Just a thought.. > >>>>> > >>>>> Excuse any errors. > >>>>> Sent from my iPhone > >>>>> > >>>>> > >>>>> > >>>>>> No pets. No cat scratches. Pt is pristine except for one swollen lymph node > >>>> and one minor abrasion on her chin. > >>>>>> > >>>>>> Alyssa Woods, NREMT-B > >>>>>> > >>>>>> > >>>>>> Sent from the itty bitty keyboard on my iPhone > >>>>>> > >>>>>> > >>>>>> > >>>>>>> Cat-scratch encephalopathy? > >>>>>>> > >>>>>>> Sent from my iPhone > >>>>>>> > >>>>>>> On Jul 12, 2011, at 1:28 PM, Brad Sattler bradsattler@...> wrote: > >>>>>>> > >>>>>>> Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > >>>>>>> > >>>>>>> -Brad > >>>>>>> > >>>>>>> Sent from my iPhone > >>>>>>> > >>>>>>> On Jul 12, 2011, at 11:22 AM, Alyssa Woods amwoods8644@...> wrote: > >>>>>>> > >>>>>>>> High-dose phenobarbital drip calms her seizures for the duration of the > >>>> drip only, the node is visibly swollen. You don't see or feel any other swollen > >>>> lymph nodes. No s/s of anemia. > >>>>>>>> > >>>>>>>> Alyssa Woods, NREMT-B > >>>>>>>> > >>>>>>>> > >>>>>>>> > >>>>>>>> > >>>>>>>>> Phenobarbitol drip? Look for s/s of anemia... How big is the node? > >>>> Reasesses paying attention for nodules? > >>>>>>>>> > >>>>>>>>> Sent from my iPhone > >>>>>>>>> > >>>>>>>>> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@...> > >>>> wrote: > >>>>>>>>> > >>>>>>>>> She did not ingest a plant. Benzo's and phenobarbital stop her seizures > >>>> for 30 seconds - 1 minute, paralytics for a few minutes. > >>>>>>>>> > >>>>>>>>> Alyssa Woods, NREMT-B > >>>>>>>>> > >>>>>>>>> > >>>>>>>>> > >>>>>>>>> > >>>>>>>>> Find out what plant she possibly ingested. Begin your normal treatment > >>>> for siezure until you know more. > >>>>>>>>> > >>>>>>>>> Henry > >>>>>>>>> Mystery Diagnosis > >>>>>>>>> > >>>>>>>>> You're called out to a 5 year old girl who was playing in the yard, > >>>> when she suddenly had a seizure. When you arrive on scene her parents instantly > >>>> calm down and tell you she has no history, no medications, and no known > >>>> allergies. Your patient is having a grand mal seizure which has been going on > >>>> for at least 5 minutes. > >>>>>>>>> > >>>>>>>>> What's your treatment and what's happening to her? > >>>>>>>>> > >>>>>>>>> Alyssa Woods, NREMT-B > >>>>>>>>> > >>>>>>>>> > >>>>>>>>> ---------------------------------------------------------- > >>>>>>>>> > >>>>>>>>> No virus found in this incoming message. > >>>>>>>>> Checked by AVG - www.avg.com > >>>>>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: > >>>> 07/11/11 18:35:00 > >>>>>>>>> > >>>>>>>>> ---------- > >>>>>>>>> > >>>>>>>>> No virus found in this outgoing message. > >>>>>>>>> Checked by AVG - www.avg.com > >>>>>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: > >>>> 07/11/11 18:35:00 > >>>>>>>>> > >>>>>>>>> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 13, 2011 Report Share Posted July 13, 2011 Dehydration? Barry Sharp, MSHP, MCHES Tobacco Prevention & Control Program Coordinator Substance Abuse Services Unit Mental Health and Substance Abuse Division Re: Mystery Diagnosis > >>>> > >>>> By which you mean metastatic cancer? No, but you're the closest one so far. > >>>> You're thinking along the right lines -- chronic, medical, and focal. > >>>> > >>>> Alyssa Woods, NREMT-B > >>>> (21) 842-6428 > >>>> > >>>> > >>>> > >>>>> Could be mets ca? Just a thought.. > >>>>> > >>>>> Excuse any errors. > >>>>> Sent from my iPhone > >>>>> > >>>>> On Jul 12, 2011, at 1:39 PM, Alyssa Woods amwoods8644@...> wrote: > >>>>> > >>>>>> No pets. No cat scratches. Pt is pristine except for one swollen lymph node > >>>> and one minor abrasion on her chin. > >>>>>> > >>>>>> Alyssa Woods, NREMT-B > >>>>>> > >>>>>> > >>>>>> Sent from the itty bitty keyboard on my iPhone > >>>>>> > >>>>>> On Jul 12, 2011, at 13:35, jeremydriver jeremydriver@...> wrote: > >>>>>> > >>>>>>> Cat-scratch encephalopathy? > >>>>>>> > >>>>>>> Sent from my iPhone > >>>>>>> > >>>>>>> On Jul 12, 2011, at 1:28 PM, Brad Sattler bradsattler@...> wrote: > >>>>>>> > >>>>>>> Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > >>>>>>> > >>>>>>> -Brad > >>>>>>> > >>>>>>> Sent from my iPhone > >>>>>>> > >>>>>>> On Jul 12, 2011, at 11:22 AM, Alyssa Woods amwoods8644@...> wrote: > >>>>>>> > >>>>>>>> High-dose phenobarbital drip calms her seizures for the duration of the > >>>> drip only, the node is visibly swollen. You don't see or feel any other swollen > >>>> lymph nodes. No s/s of anemia. > >>>>>>>> > >>>>>>>> Alyssa Woods, NREMT-B > >>>>>>>> > >>>>>>>> > >>>>>>>> > >>>>>>>> > >>>>>>>>> Phenobarbitol drip? Look for s/s of anemia... How big is the node? > >>>> Reasesses paying attention for nodules? > >>>>>>>>> > >>>>>>>>> Sent from my iPhone > >>>>>>>>> > >>>>>>>>> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@...> > >>>> wrote: > >>>>>>>>> > >>>>>>>>> She did not ingest a plant. Benzo's and phenobarbital stop her seizures > >>>> for 30 seconds - 1 minute, paralytics for a few minutes. > >>>>>>>>> > >>>>>>>>> Alyssa Woods, NREMT-B > >>>>>>>>> > >>>>>>>>> > >>>>>>>>> > >>>>>>>>> > >>>>>>>>> Find out what plant she possibly ingested. Begin your normal treatment > >>>> for siezure until you know more. > >>>>>>>>> > >>>>>>>>> Henry > >>>>>>>>> Mystery Diagnosis > >>>>>>>>> > >>>>>>>>> You're called out to a 5 year old girl who was playing in the yard, > >>>> when she suddenly had a seizure. When you arrive on scene her parents instantly > >>>> calm down and tell you she has no history, no medications, and no known > >>>> allergies. Your patient is having a grand mal seizure which has been going on > >>>> for at least 5 minutes. > >>>>>>>>> > >>>>>>>>> What's your treatment and what's happening to her? > >>>>>>>>> > >>>>>>>>> Alyssa Woods, NREMT-B > >>>>>>>>> > >>>>>>>>> > >>>>>>>>> ---------------------------------------------------------- > >>>>>>>>> > >>>>>>>>> No virus found in this incoming message. > >>>>>>>>> Checked by AVG - www.avg.com > >>>>>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: > >>>> 07/11/11 18:35:00 > >>>>>>>>> > >>>>>>>>> ---------- > >>>>>>>>> > >>>>>>>>> No virus found in this outgoing message. > >>>>>>>>> Checked by AVG - www.avg.com > >>>>>>>>> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: > >>>> 07/11/11 18:35:00 > >>>>>>>>> > >>>>>>>>> Quote Link to comment Share on other sites More sharing options...
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