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Story for team:
Dispatch Center Report:
84 years old woman calls from a flat because of dyspnea which started 4 hours ago. Distance of flat from EMS station is 20 km. Probably cardiac decompensation.

Your task is:
• pre-hospital emergency medical care at this case
• routing to definitive care

Local situation:
A  Nearest hospital is 20 km by ground transport with surgery, internal medicine, anaesthesia and general intensive care dept., neurology, gynecology and obstetric, CT scan and  biochemistry.
B Higher level hospital 42 km by ground transport, dept. as A + ED, ENT, oncologic dept., psychiatry, infectious diseases and pediatric dept.
C Specialized centre 55 km by ground. Depts. as B + traumacentre, burn unit, cardiocentre, stroke unit, NMR.
D Helicopter rescue available at 15 mins.

Older woman, cooperates with limits, anxious, lives alone in a flat with evidently limited social background. She sits on a chair at the arrival of crew, slight rest dyspnea, first what   she complains about is complicated breathing. At retrieval of detailed patient history patient also complains about pain in right upper extremity. At retrieval of complete patient
history (what is the main symptom?) patient complains about the pain in right upper extremity as dominant. She had similar pain yesterday, but it vanished after few hours. Does not   remember drugs, she only knows that she takes drugs for blood pressure and that she had cerebral stroke years ago. Drugs can be found in the flat (tablet – pentoxyfylin, Aspirin 30  mg, diltiazem 90 mg, amilorid, simvastatin, Digitoxin 0,125).

BP 180/80, HR 90, SpO2 89 %, GCS 14/15 (replies with latency, anxious, but not desoriented).
ECG: sinus rhythm 100/min., QS V1-3, hypertrofic left ventricle, definite signs of acute ischaemia are not present, in physical findings sound systolic murmur at precordium, light perimalleolar swellings om both sides, upper right extremity cold from elbow, insensible, but there are no striking mobility limitations, no pulse at radialis artery, normal pulse wave  at brachilais artery. Other physical findings normal (breathing clear...).

Point of task:
To point out the importance of complete patient history retrieval by patient with limited but not excluded cooperation in EMS conditions, exclude misleading report of dispatch   centre and primary informations on site), art of retrieving maximum of informations at the absence of any medical documentation on site, importance of found drugs for differential  diagnostics. Detailed physical examination. Adequate therapy with sufficient analgesia. Optimal target medical facility with arterographic X ray and vascular surgeon.