This document provides an overview of a case study involving an 86-year-old male patient found supine on his couch by EMS, unresponsive and cyanotic. His daughter reports he has had increasing trouble breathing over the past few days. Upon assessment, the patient appears to be in respiratory distress with low oxygen saturation. The case study prompts the reader to consider how to proceed with assessment and management of this patient.

1. Advanced Medical Life Support, 3e
CASE STUDY
Dalton, Limmer, et. al.
You are dispatched to an elderly patient for “respiratory distress for the past several days.” You arrive on the scene and
are greeted at the door by the patient’s daughter. As you walk in, you scan the scene for safety hazards. You find the 86-
Prentice Hall, © 2007
year-old patient, who does not appear to be alert, lying supine on the couch. His daughter tells you, “He started com-
plaining last week that he was having some trouble breathing. He had a cold, and I thought that was all it was. But it’s
gotten much worse over the last few days. He wouldn’t let me take him to the doctor or emergency department.” You
Interior and Cover Design
notice an oxygen tank in the corner of the room. He had a cold, and I thought that was all it was. But it’s gotten much
worse over the last few days. He wouldn’t let me take him to the doctor or emergency department.” You notice an oxy-
gen tank in the corner of the room.
Photo research of opener/cover
As you approach the patient, you note that he appears cyanotic. He does not move or respond when you call his
name.
How would you proceed with the assessment and management of this patient?
image and 1 head icon.
Photoshop work on those images
INTRODUCTION
ASSESSMENT
1 When responding to an emergency scene, many questions enter the mind of
Programs: Quark, Photoshop
the EMS professional. What are the possible conditions the patient might be suf-
OF THE MEDICAL PATIENT fering from? Will there be key information available that will allow me to deter-
mine the condition the patient is most probably suffering from? What treatment
will be required? How quickly will I need to proceed with the treatment? Will crit-
ical interventions be necessary, such as endotracheal intubation or drug therapy?
n accurate and reliable patient assessment is one of the most important Will I need to change the treatment based on additional information gained in the
A history or physical examination? Will I need to transport the patient rapidly?
skills that is performed in the prehospital environment. The EMS
professional must rely primarily on information gathered in the patient history
Categorize the Patient: Medical vs. Trauma
and on physical assessment findings to develop an appropriate approach to the
A decision the EMS professional must try to make very early in the assessment is
patient, identify priorities, and establish an emergency care plan. Developing a
whether this is a medical or a trauma patient. You can usually do this on the basis
systematic assessment routine that you follow for every patient will increase your
of the dispatch information and as part of your scene size-up. However, some
confidence in your assessment skills and ensure that life-threatening conditions scenes are very confusing and lack a wealth of overt clues as to whether the patient
will be managed prior to other, non-life threats that may present more was injured or is ill. You may not be able to determine the real nature of the
patient’s problem until you do the focused history and physical exam. You must
dramatically.
always be prepared to change your direction of thought and focus based on further
assessment findings. Dispatch information can be erroneous, or the patient’s real
Topics that will be covered in this chapter are: complaint can turn out to be something other than what you suspected when you
formed your first impression.
Components of the Medical Assessment
Further, you must categorize the patient not only by mechanism of injury or
Dispatch Information Clinical Insight nature of illness, but also—based on some very objective clinical indicators in the
Scene Size-up initial assessment—you must determine if the patient is physiologically stable or
A Babinski reflex,
unstable. The unstable patient will require immediate intervention and a much
Physiologically Stable or Unstable Criteria dorsiflexion of the
more aggressive and rapid management plan. Categorizing the patient by degree of
Initial Assessment great toe with fanning
stability will allow you to manage immediately life-threatening conditions before
and extension of the
Focused History and Physical Exam proceeding to form differential field impressions as the basis for advanced patient
other toes, may a
normal presentation in
Possibilities to Probabilities: Forming a Differential Field Diagnosis management.
an epileptic postictal
Based on this assessment model, any immediately life-threatening conditions
Detailed Physical Exam patient.
will be managed very early in the assessment process. Once these conditions are
Ongoing Assessment
1
11
Scene Size-up
INTRODUCTION
ADVANCED
The case studies that follow include two kinds of material: a running narra-
tive of the case and, in italics, a commentary on the case. Each segment ends with a
question or two in red type to encourage you to stop and think about what you
have just read—to ponder, analyze, speculate, or discuss with fellow students or
MEDICAL
your instructor—before you read the commentary or the next section.
CASE STUDY SCANARIOS
LIFE SUPPORT
CASE 1: DIFFICULTY BREATHING
THIRD EDITION
At 18:00 hours you are dispatched to a 56-year-old male with difficulty breathing.
On arrival, you find him leaning over the kitchen table, struggling to breathe. He is
awake and appears very pale. He is clutching an inhaler in his left hand. As you
introduce yourself and begin an assessment, you note that his skin is cool and
clammy. He has a radial pulse of 100, respirations of 24 with intercostal retractions,
and a blood pressure of 156/90. He talks in two-to-three-word sentences. He tells
you he started having trouble breathing this afternoon and has been getting
steadily worse. He has had no relief from his inhaler. He denies chest pain but does
admit to feeling a “weight” on his chest. He is on Ventolin (albuterol) and Vasotec
(enalapril). Pulse oximetry reads 86%. When asked to rank the “weight” on a 1–10
scale, he states, “It’s a 6.” What is this patient’s problem? Have you noted any clues,
so far, to the underlying cause? What is your immediate task?
This patient has several signs of acute dyspnea. An inability to talk in complete sentences that
indicates inadequate minute volume which, at rest, is abnormal. His respiratory rate is 24 with
intercostal retractions, which indicates labored breathing, and the pulse oximetry is 86%, well
below normal. His tachycardia may be due to his hypoxia. This man is in acute respiratory dis-
tress. The task here is first to support vital functions, then to figure out the most likely cause so
appropriate treatment can be implemented. The feeling of quot;weightquot; on his chest implies car-
diac involvement. How should you proceed with assessment? with care?
While you are placing a nonrebreather mask with reservoir on the patient at
15 lpm, your partner is attaching the cardiac monitor.
The patient reports a history of asbestosis, hypertension, and insulin-depen-
dent diabetes. Last year he had a triple bypass done. He has bilateral wheezes, most
pronounced in the bases.
While your partner starts an IV of normal saline, you have the patient rinse
out his mouth with water and give him a nitroglycerin tablet sublingually. Why did
you have the patient rinse his mouth? Why did you give nitroglycerin? What addi-
tional clues to the etiology of his problem have you gathered?
The concern here is the cardiac implication of the patient feeling a “weightquot;” on his chest. It is
prudent to interpret this as a description of cardiac involvement, although patients with COPD
or asthma will also report chest “tightness” with bronchospasm.
This patient’s choice of words and cardiac history are more typical of angina, which is a logical
result of poor oxygenation of heart muscle (pulse oximetry value of 86%).
Dalton Limmer Mistovich Werman
Additional contributing factors include his cardiac history (bypass last year)
and being an insulin-dependent diabetic. Diabetics are very prone to peripheral

2. Medical Neuroscience
Nadeau, Ferguson, et. al.
Saunders, © 2004
Book Design, including Photoshop
work on Unit and Cycle art
Programs: Quark, Photoshop
CYCLE 1-1 DIRECTIONAL TERMS AND OTHER BASIC NEUROANATOMIC NOMENCLATURE
7 9
CYCLE 1-1 DIRECTIONAL TERMS AND OTHER BASIC NEUROANATOMIC NOMENCLATURE
Duis autem vel eum iriure dolor in hendrerit in in vulputate velit esse molestie consequat, vel illum
Introduction THROMBOSIS IN
THE ROLE OF Duis autem vel eum iriure dolor in hendrerit in vulputate
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PATHENOGENESIS OF STROKE velit esse molestie consequat, vel illum dolore eu feugiat
eu feugiat nulla facilisis at vero eros et accumsan et iusto et iusto odio dignissim qui blandit praesent luptatum nulla facilisis at vero eros et accumsan et iusto odio dig-
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augue duis dolore te feugait nulla facilisi. Nam liber Lorem ipsum dolor sit amet, consectetuer adipiscing elit, duis dolore te feugait nulla facilisi.
velit esse molestie consequat, vel illum dolore eu feugiat
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D
The following websites can be useful:
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assum. Lorem ipsum dolor sit amet, consectetuer adip- laoreet dolore magna aliquam erat volutpat. Ut wisi
duis dolore te velit esse molestie consequat, vel illum
vulputate feugait nulla facilisi. http://www.neurophys.wisc.edu/brain/
iscing elit, sed diam nonummy nibh euismod tincidunt ut enim ad minim veniam, quis nostrud exerci tation ullam-
• dolore eu feugiat nulla facilisis at vero eros et
PRACTICE 1.2 the aorta
laoreet dolore magna aliquam erat volutpa nonummy corper suscipit ad minimnisl ut aliquip nostrudcommodo
Ut wisi enim lobortis veniam, quis ex ea exerci
accumsan et iusto odio dignissim qui blandit praesent
nibh euismod tincidunt ut laoreet dolore magna aliquam • the proximal extracranial portions of the internal tation ullamcorperwisi enimlobortis nisl ut aliquip ex ea
consequat. Ut suscipit ad minim veniam, quis nostrud
luptatum zzril delenit augue duis dolore te feugait nulla
erat volutpat. Make sure you know the meaning and location of the carotid arteries (just distal to the common artery commodotation ullamcorper suscipit lobortis nisldolor in
exerci consequat. Duis autem vel eum iriure ut aliquip
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ex ea in vulputate velit esse molestie consequat, iriure
option congue nihil imperdiet doming id quod mazim
elit, sed diam nonummy nibh euismod tincidunt ut dolor in hendrerit in vulputate velit esse molestie conse-
illum dolore eu feugiat nulla facilisis at vero eros et
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• the distal most, intercranial portions dolor sit
gyri
sulci
laoreet dolore magna aliquam erat volutpat. Ut wisi accumsan et illum doloredignissim qui blandit praesent
quat, vel iusto odio eu feugiat nulla facilisis at vero
bral-arteries.
cerebral cortex
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enim ad minim veniam, quis nostrud exerci tation ullam- luptatumet accumsan et iusto odio dignissim qui nulla
eros zzril delenit augue duis dolore te feugait blandit
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facilisi.
parietal lobe
elit, sed diamvel eum iriure dolor in hendrerit in ut
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laoreet dolore magna aliquam erat volutpat. Ut wisi
temporal lobe
in vulputate velit esse molestie consequat, vel illum parietal lobe elit, sed diam nonummy nibhdiam nonummy nibh ut
sectetuer adipiscing elit, sed euismod tincidunt euis-
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dolore eu feugiat nulla facilisis at vero eros et accumsan temporal lobe laoreet dolore magna aliquam erat volutpat. aliquam erat
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et iusto odio dignissim qui blandit praesent luptatum occipital lobe volutpat. Ut wisi enim ad minim veniam, quis nostrud
augue duis dolore te feugait nulla facilisi. Nam liber http://www9.biostr.washington.edu/da.html
consequat.
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thalamus tempor Duis autem nobis eleifend option congue nihil in
cum soluta vel eum iriure dolor in hendrerit
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http://www.anatomy.wisc.edu
hypothalamus
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sed diam nonummy nibh euismod tincidunt ut laoreet am, quis nostrud exerci tation ullamcorper suscipit
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consequat. Duis autem vel eum iriure dolor in hendrerit consequat. Duis autem vel eum iriure dolor in hendrerit http://www.med.Harvard.edu/AANLIB/cases/caseM/
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T A B L E 1-1 Structures and their Functions
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1. DeArmond toward the midline
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In human brainstem and spinal cord:
Superior colliculus Virtual system New York.
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and skull velocity at the moment of luptatum literally torn
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the duis notwithstanding the stabilizing force of the falx
2, Nolte J, Angevine JB, The Human Brain. St Louis:
caudal = posterior =- back
Mosby, 1995.

3. Pillsbury Fix It Fast!
Interior Design Proposal (design
on following page was chosen)
Programs: Quark, Photoshop,
Illustrator
MARINATED
Yield: 4 servings
1 Heat the grill. Shape and cook the ground beef patties.
MUSHROOM–TOPPED
MARINATED MUSHROOM–TOPPED BURGERS BURGERS
2 While the patties cook, slice two tomatoes and arrange on
FRESH TOMATO AND LETTUCE
bibb lettuce or mixed salad greens. Serve with favorite salad
READY IN 20 MINUTES SALAD
dressing.
Yield: 4 sandwiches
PICKLES AND OLIVES
3
1
/4 cup balsamic vinaigrette
1 lb. lean (at least 80%) ground beef Toast rolls and make the burgers; serve with pickles and
11/2 teaspoons lemon-pepper seasoning S’MORES NACHOS
4 kaiser rolls, split
olives.
2 cups sliced fresh mushrooms (about 5 oz.) 4 (1-oz.) slices Swiss cheese
4 For dessert, heat the broiler. Make the s’mores nachos.
4 To toast rolls, during last 1 to 2 minutes of
1 Heat gas or charcoal grill. In medium
cooking time, place rolls, cut sides down,
bowl, combine ground beef and 1 tea-
on grill. Place 1 slice of cheese on each
spoon of the lemon-pepper seasoning;
mix well. Shape mixture into 4 1/2-inch- patty; cook an additional minute or until
S’MORES NACHOS [SUPERFAST]
cheese is melted.
thick) patties.
2 In another medium bowl, combine
READY IN 5 MINUTES
mushrooms, remaining 1/ 2 teaspoon
Yield: 4 servings
lemon-pepper seasoning and vinai-
8 rectangular graham crackers
grette; toss to coat. Set aside. 3
/4 cup milk chocolate chips
3 When grill is heated, place patties on
11/2 cups miniature marshmallows
gas grill over medium heat or on char-
coal grill 4 to 6 inches from medium
1 Break each graham cracker into 4 2 Broil 6 inches from heat for 30 to 60
coals. Cook 11 to 13 minutes or until 1 SERVING
Calories 340 (Calories from
pieces. Pile pieces in ungreased metal
patties are thoroughly cooked, turning seconds or until marshmallows are Fat 110); Total Fat 12g
(Saturated Fat 6g);
or disposable foil pie pan. DO NOT USE
once. puffed and golden, watching to prevent Cholesterol 5mg; Sodium
GLASS. Top with chocolate chips and burning. 190mg; Total Carbohydrates
55g (Dietary Fiber 1g); Sugars
marshmallows.
1 SANDWICH 40g; Protein 4g, % Daily
Calories 555 (Calories from Fat 295); Total Fat 33g (Saturated Fat 13g); Cholesterol Value: Vitamin A 0%; Vitamin
90mg; Sodium 1,060mg; Total Carbohydrates 29g (Dietary Fiber 1g); Sugars 1g; Protein C 0%; Calcium 6%; Iron 6%
35g, % Daily Value: Vitamin A 6%; Vitamin C 0%; Calcium 32%; Iron 22% Exchanges: 1 Starch, 21/2,
The popular campfire s'mores use chocolate but for a flavor twist use butterscotch or peanut butter
Exchanges: 2 Starch, 4 Medium-Fat Meat, 21/2 Fat Fat, 21/2 Other Carbohydrates
chips rather than the milk chocolate chips. Kids of all ages will love them
Carbohydrate Choices: 2 Carbohydrate Choices: 31/2
BROILED MARINATED MUSHROOM–TOPPED BURGERS
minutes of cooking time, place rolls, cut sides
Place patties on broiler pan; broil 4 to 6 inch-
up, on broiler pan. Place 1 slice of cheese on
es from heat using times above as a guide,
each patty; cook an additional minute.
turning once. To toast rolls, during last 1 to 2
Mushroom slicing is a thing of the past! Just look for packages of presliced
mushrooms next to the whole mushrooms in the produce department. They're a
great recipe time-saver!
8 9

4. Pillsbury Fix It Fast!
Three Skillet Beefy Chili Mac Wiley, © 2006
Skillet Beefy Chili Mac
Jump Start with Pasta
Ready in 25 minutes 4 servings (1 1/2 cups each)
Fettuccine with Beef and Peppers
Interior Design and full composition
Menu
1 1/2 cups uncooked elbow macaroni (6 oz.)
IItalian Mixed Salad
1 lb. lean (at least 80%) ground beef
Beef and Ramen Noodle Bowls
Program: Quark
1 can (15 oz.) spicy chili beans, undrained
Skillet Meatballs with Linguine
Menu
1 can (14.5 oz.) diced zesty chili-style tomatoes, undrained
Corn with Chives 1/4 teaspoon salt
1/4 teaspoon pepper
Beef and Pasta Alfredo
1 cup shredded Cheddar cheese (4 oz.)
Easy Ham and Noodles
Caesar Tortellini with Ham 1 SERVING
Cook macaroni as directed on package. Drain; return to
Calories 595 (Calories from Fat 245);
Basil-Pork and Asian Noodles saucepan. Cover to keep warm. Total Fat 27g (Saturated Fat 13g);
Cholesterol 95mg; Sodium 1,490mg;
Meanwhile, in 12–inch nonstick skillet, cook ground beef over
Tuna and Ham with Fettuccine Total Carbohydrates 55g (Dietary Fiber
medium-high heat for 5 to 7 minutes or until brown, stirring 7g); Sugars 6g; Protein 40g
Ravioli with Broccoli,Tomatoes and Mushrooms % Daily Value: Vitamin A 22%; Vitamin C
frequently. Drain.
Penne with Cheesy Tomato-Sausage Sauce 20%; Calcium 22%; Iron 34%
Reduce heat to medium. Stir in cooked macaroni, beans, Exchanges: 3 Starch, 4 1/2 Medium-Fat
Chicken Puttanesca Sauté Meat, 1 Fat
tomatoes, salt and pepper. Cook an additional 3 to 5 minutes Carbohydrate Choices: 0
Two-Cheese Chicken with Couscous or until bubbly, stirring frequently. Sprinkle with cheese.
Southwest Chicken and Fettuccine
Tortellini with Chicken
Menu
Strawberry-Rhubarb Sundaes
QUICK
FIX
If you don't have a can of zesty chili-style tomatoes on hand, use a can of plain diced
Creamy Chicken and Asparagus tomatoes and add 1/2 teaspoon chili powder.
Lemon-Chicken Primavera
Ravioli with Corn and Cilantro
Three-Pepper Pasta with Pesto
Menu
Peas with Dill
Pesto Shrimp and Pasta
Summer Vegetable Ravioli
69
JUMP START WITH PASTA
Chicken, Vegetable and Cream
Cheese Sandwiches
n n n n Ready in 10 minutes 4 sandwiches
8 slices pumpernickel rye bread
1 container (6.5 oz.) gourmet spreadable cheese with garlic and
herbs (1 cup)
16 thin slices cucumber
1 lb. sliced cooked chicken (from deli)
1 medium tomato, sliced
1 slice (1/4 inch thick) sweet onion (Walla Walla, Maui or Texas
Sweet), separated into rings
1 cup coleslaw mix (from 16-oz. bag)
1 SANDWICH
Spread one side of all slices of bread with gourmet spreadable
Calories 480 (Calories from Fat 250); Total
cheese. Fat 28g (Saturated Fat 13g); Cholesterol
95mg; Sodium 2,040mg; Total
Top 4 bread slices, cheese side up, evenly with cucumber, Carbohydrates 34g (Dietary Fiber 4g);
chicken, tomato, onion and coleslaw mix. Cover with Sugars 7g; Protein 23g
% Daily Value: Vitamin A 20%; Vitamin C
remaining bread slices, cheese side down. 22%; Calcium 10%; Iron 16%
Exchanges: 2 Starch, 2 1/2 Lean Meat, 4 Fat
Carbohydrate Choices: 2
QUICK
FIX
Everyone on a different schedule? You'll feel good when you have these tasty sandwiches
in the refrigerator, wrapped and ready to eat for family members who are on the go!
10 11
PILLSBURY FIX IT FAST!