Puzzled over a recent patient's visit to an Emergency Department.

Specialties Emergency

Published

I'd like to pose a scenario for everyone's consideration, and feedback.

Looking at this ECG, please consider this pt is a 38 year old male, 6' and 260 pounds. Pt reports a h/o hypertension and tachycardia (both controlled by meds); chronic shortness of breath (likely attributed to his 'rotund' abdomen); and a (suspected but unconfirmed) h/o DIC, requiring multiple transfusions, after an 8 week premature birth.

This pt reports a normal stress test in 11/2013 and a normal ECG in 01/2014. During the past 5 days, this pt c/o increased effort w/ respiration, periods of dizziness and near-syncope. Additionally intermittent chest discomfort accompanied by a sensation of blood released/rushing to his upper extremities, and mottled hands with profuse itching. Pt also reports now waking with bilateral non-pitting edema in both feet. All of the c/o began approximately 5 days ago, and have increased in both intensity and frequency during this time.

BP 120's/80's, HR 90-100's, RR 20-24, SaO2 91-93% RA, and T 97.4

All labs, including cardiac enzymes, are WNL, except D-dimer 0.68; Na 133; WBC 13.4, and glucose 138. A CAT scan to r/o PE is negative.

After several hours in the ED, despite no relief from his s/s, this pt was D/C home to f/u with PMD the next day.

I'd love to hear any thoughts/feedback that anyone has to offer.

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Are you struggling with the d/c home? The results? Ha ha I'm not sure what feedback you're looking for

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Specializes in Emergency Department.

One problem I can see immediately is that there's no ECG to look at... at least not one that I can see.

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I guess I could say that the stress test and ECG that old means nothing.

Good baseline but you need to compare.

Just based on what you said, I wouldn't feel comfy d/c home with those symptoms. Baby needs more work up.

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I'm not sure what kind of feedback you're looking for. I don't see any EKG. His hand symptoms sound like they could possibly be Raynaud's Phenomenon, which can be associated with autoimmune disease.

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Sorry, folks, this was my first attempt at posting on here. I'm puzzled due to the pt's d/c home. Can't shake the feeling that something was missed.

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Any stress test over a year old is practically useless, and an old normal ECG is also useless, other than for comparison to an ECG when the patient is having symptoms. Given that PE was ruled out, and I'm assuming the imaging of his chest was otherwise negative, as well as negative Troponin,with normal labs, my main consideration would be that his symptoms represent anxiety, especially with the complaints of "rushing feelings" in his extremities and the itching in his hands.

However, his pulse ox is kind of low for anxiety, as usually these patients hyperventilate (which can cause the "rushing" symptom, or symptoms of numbness or tingling to the extremities) and have pulse ox of at least around 98%. Was he a smoker? Did they do cardiac enzymes x3, or just one? Because sometimes a negative Troponin x1 is not enough to rule out cardiac damage. Also, you did not provide an ECG. Something else that could cause his symptoms would be something like a cardiac dysrhythmia, PVC's or PAC's which can be generally benign, or some kind of atypical pericarditis.

Since he is 38 and obese, with h/o HTN, if he had a strong family h/o CAD or was a longterm smoker, he would likely be admitted short stay where I work for further cardiac workup and monitoring, such as a CTA coronaries. But, if there is no emergent process evident, you have to remember that this is the ER and that when there is no emergent process evident, and with minimal comorbidities, it is not always practical to admit these patients if they have close f/u with their PCP. If there is no solid reason to admit, it is reasonable to d/c them

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The pt did report a strong family history of CAD, and also 1 ppd smoker x 15 years.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Is this for school?

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Then where I work, where the docs tend to be as I understand, kind of conservative, they would at least keep for serial cardiac enzymes, monitoring, and some kind of cardiac rule out testing in the morning such as CTA or stress test in the morning. Stress tests are limitedly helpful if someone has multiple risk factors as the "normal stress test" results expire within a year or two. But if you cannot get someone's heart rate down below the 60's for a CTA, it is very difficult to do. If the patient had reliable f/u and wanted to go home and felt better, he may just be d/c'ed, however, depending on the doctor

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No, this is simply for my own peace of mind. I didn't fee good about this pt's d/c, as my gut instinct was that we'd missed something.

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dayna.tulip, the stress test was from November of 2013.

DeannaMiller,

Please remember that the role of the ED physician is not necessarily to provide a definitive diagnosis. Once an immediate life threat has been ruled out, further workup to diagnose the problem is not indicated, hence the follow up with the PCP.

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