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Case Review By James J. Augustine, MD, FACEP ‘Not Like Herself at All’ A woman’s sudden unusual behavior may have dire origins The Attack One crew arranged a special lunch for a member who had to spend his birthday away from his family. After ﬁnishing Initial Assessment lunch in the restaurant, the crew is waiting for the small cake that A 64-year-old female acting in an unusual fashion. will mark the event. But as their waitress approaches the table, Airway: Intact and uncompromised. she has no cake in her hands. She asks if one of the crew members Breathing: No distress. could step back to the kitchen to help an employee of the bakery Circulation: Normal capillary refill, pink skin. across the street, who had just delivered the cake. The paramedic Disability: New and apparently sudden onset of leaves the table and follows the waitress back to the kitchen area, erratic behavior. Patient suddenly became very where there’s a woman in the employee restroom. The waitress tells the paramedic, “That lady is just acting strangely—not like disoriented, with an erratic speech pattern. She moves herself at all.” From outside the door, the paramedic can hear extremities without deficit, and overall is restless, the woman in the restroom vomiting. Another female restaurant moving around on the chair and cot. employee is in there assisting her, and when the vomiting stops, Exposure of Other Major Problems: Sudden the paramedic can hear their conversation through the door. The vomiting. ill woman makes no sense as she talks to the restaurant worker. Vital Signs “ Any delay The paramedic knocks on the door, identiﬁes himself and asks if he can help. The restaurant worker invites him in. “This lady,” she says, “is just not acting like herself at all.” The medic thinks Time HR BP 1240 104 180/110 18 98% 92 1247 100 180/106 20 98% RR POx BS it notable that both employees used almost the exact same words. would The woman has stopped vomiting and now sits restlessly on 1254 100 174/100 20 97% AMPLE Assessment have the toilet. As the medic interviews her, she intermittently speaks Allergies: None. coherently, then mumbles a few words, then makes no sense at all resulted in before returning to coherence. He asks if she’s diabetic, and she Medications: None. says she has no medical problems. She adds she has some pain in Past Medical History: Intermittent headaches. No a terrible her head, but has a history of headaches. history
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