Case Study (September 13th, 2024)

🚑 🚨 You and your partner have been dispatched to a private residence for a female party with SOB.
Upon arrival, you find the patient in the care of her husband. She is a 65-year-old female with a hx of mild COPD, type-2 diabetes, hypothyroidism, and HTN. Per her husband, she has been complaining of new-onset productive cough, weakness, malaise, anorexia, and general weakness x4 days. Today, she developed SOB while ambulating to the restroom and has not been able to catch her breath in over an hour, prompting the call to 911.
You perform an assessment while your partner obtains vitals:
Physical exam is significant for:
NEURO: Lethargy, follows simple commands.
CV: Weak peripheral pulses, cap refill -3 sec
RESP: Diminished L lung, rales/rhonchorous R lung (middle). Moderate SOB w/ increased WOB.
OTHER: Warm, mild diaphoresis, poor skin turgor.
Vitals:
HR: 124
BP: 84/52
RR: 36
SpO2: 85% RA
Temp: 103.5 F (39.8 C)
Glucose: 184 mg/dL (10.2 mmol/L)
You stairchair the patient out of the house and load her safely in the ambulance. The regional hospital is 35 minutes away.
❓ What is your working diagnosis?
❓ What are your primary concerns?
❓ How would you manage this patient?
Catch the breakdown with Dean later today!
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[@mobee5764]

Pneumonia with concern for septic shock, Start with fluids and methylprednisolone. Im an EMT fyi just my guess.