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

dayna.tulip · May 5, 2014

That is correct. Everything immediately life threatening had been ruled out. A CT chest would have shown PE, signs of aortic dissection, or another pulmonary process. Cardiac enzymes would have shown if there was cardiac damage. However, sometimes there is a process that is life threatening, that is not evident at the time. But when the patient was d/c, there were no abnormal studies to suggest that he had a life threatening process going on at that time.

I'm saying though, that often I have seen one negative Troponin, and then the next one was significantly elevated and the patient is diagnosed eventually with NSTEMI. If they did not do more than one Troponin, then they have not completely ruled out cardiac damage. It takes hours after cardiac damage occurs for Troponin to come back positive, and if his symptoms started just shortly before coming in, say 2 hours, and the first Troponin was negative, there is still a good chance that the second one would have been positive

However, with a negative Troponin, D-Dimer, CBC, electrolytes and renal function, and with normal vitals, and ECG, AND a negative CXR and chest CT, it is VERY unlikely that there is an emergent process going on at that time. Perhaps the patient is having early signs of cardiac disease that have not yet caused measurable heart damage, which is why f/u and treatment is important

Anna Flaxis, BSN, RN · May 5, 2014

That is all very true, except keep in mind that the patient's symptoms began 5 days ago, which is plenty of time for Troponin to become elevated, and are described as "intermittent", which makes it less likely to be MI.

This information is just as important as labs and diagnositics in helping the physician to diagnose the problem. You can't just look at the labs and diagnostics alone. This is why physicians take a history and do a physical exam.

Guests · May 5, 2014

My first impression is that there's no "What's new today" complaint... just a progressively worsening condition of an unhealthy, obese man who's already getting routine care.

There's much talk about what he reports but no mention of remarkable findings on exam. Regardless of what he says, what do we find in front of us... are there concerning s/sx of an acute process or is this a dude in need of nutritional counseling and adjustment of medications?

His vital signs are mildly concerning because he's mildly tachycardic, mildly tachypneic, and his oxygenation is mildly low... no real danger signs but, combined with everything else, might give one cause for pause.

This guy wouldn't leave quickly... a minimum of three sets of cardiac enzymes... perhaps a bedside echocardiogram... probably a BNP (which isn't mentioned)

Whether he was d/c'd home or not would depend on the specifics of the physical exam, how he reacted while in the ED, whether he felt able to go home, and his ability to seek follow-up care... he clearly has need of intervention but there's no giant red flag arguing for admission for what seem to be chronic problems. Probably this guy would get admitted but it's not a carte blanche ticket into the tele unit.

Other things that we would do... orthostatic vitals, ambulating oximetry, BNP, CXR... the hx of syncope *might* buy him a head CT... my docs are very liberal with spinning heads.

Home Health Columnist / Guide · May 6, 2014

Always trust your gut....ask for second set of doc eyeballs when you have that doom feeling. Would have stayed overnight in observation at my facility..members already gave ideas re additional test, esp echo. You may never know outcome or might be repeater in next 24hrs if something acute manifests itself.

That Guy, BSN, RN, EMT-B · May 6, 2014

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.

Did you raise your concerns with the doc?

DeannaMiller · May 7, 2014

I did make an attempt to raise my concerns with the doctor, however she (a locum tenem); didn't seem to have any interest, and presented herself as very dismissive, in respect to my concerns. It seemed as though she already had her tunnel-vision solely focused on how quickly she could d/c this pt.

As a result,

Anna Flaxis, BSN, RN · May 8, 2014

As a result......?

What were concerned might have been going on with this patient?

Remember that in the ED, often diagnosis is that of excluding acute life threatening illness. Once AMI, PE, aortic dissection, pneumonia, etc. has been ruled out, chasing down a diagnosis is not practical. To admit, you have to have an admittable diagnosis. Even to admit for observation, there needs to be a strong clinical index of suspicion that an acute process is occurring that just hasn't declared itself yet.

Another angle is that often the physician will offer the patient the choice to remain overnight for observation or go home with timely PCP follow up. Perhaps the patient wanted to go home rather than stay for observation?

MunoRN, RN · May 11, 2014

15 years ago that might have been a likely admit, times change. If the potential cardiac symptoms had started

Christy1019, ASN, RN · May 12, 2014

On a side note, the mottled hands with itching is something I haven't heard of in my 6yrs experience, I know of numbness/tingling associated with anxiety but not these symptoms. Does anyone have any insight on that?

Anna Flaxis, BSN, RN · May 12, 2014

As I previously mentioned (post #4), mottling and itching in the hands can be caused by Raynaud Syndrome.

Christy1019, ASN, RN · May 12, 2014

I'm sorry, I did see that but have a terrible memory and the attention span of a fruit fly lol, forgive me.