[limabean]

Can anyone help me figure out what is going on with this patient? Female pt came in with COPD exacerbation, Chest pain. Troponin on admission was neg but did go up to 0.45 on 2nd draw. Cardiology was consulted who said there were Qwaves in a few leads but that no acute ischemic changes were noted (however they did put her on Heparin). They wanted to wait until she was cleared from a resp standpoint before doing a heartcath. Well about a week ago she was not doing too bad. She was able to get up to the bedside commode with no problem. Now today and yest she was EXTREMELY short of breath even to reposition herself in bed, RR of about 60 when she moved at all! Her heart rate which was in the 80's to 90's is now progressing up and is staying in the 130's -140's Sinus Tach. It goes up to about 180 when she moves. Well I called the doc asap this am b/c her WBC went up from about 7.0 to 20 in 4 days time plus I wanted him to know that she did not look good at all. We did stat ABG's and stat port cxr. CXR showed no infiltrate or anything else. ABG's showed metabolic alkalosis with low pO2 at about 58L on 5L O2 NC. I called this to the doc who said the WBC was probably the prednisone. He said to give her a dose of lasix. (Also we checked her Troponin again and it was negative.) I called him several times in the day and he did not seem to be too worried. Also her H&H had dropped from normal to 10.3 and 30. I thought "well maybe she has a bleed." - with the ST, she was pale, and all. I dont know! The doc said we are doing all we can do...and he kept writing in the progress notes that she was getting better. This does not really seem better to me. I really thought she was going to code today. I dont know how a person can continue like this not being able to breath at all ...and this is a big change from how she was about a week ago. (Just a few tidbits to add..I dont know if this helps...BP has been about 140/90's for days today it was 120/80's ...no temp...o2 sat is 95% on 8L high flow NC...she is on cardizem for HR...she has had a pain in her left groin for a couple days and she says her leg is numb from the groin to the knee, but they have done x-rays, US etc. good pulses and they are all neg).
Thanks for any help you guys can give. I am just really worried about this patient. Am I missing something?

[earle58]

is she febrile? any palpable lymph glands (esp in groin)? did the dr. get a sed rate?

leslie

[limabean]

no..she was afebrile. We figured out today what was going on. She had a retroperitoneal bleed. They did a stat ct scan this am b/c her H&H had dropped from 10.3 and 30 to 25 and 8. The pt got 2 units of blood and she is already feeling better...HR down to 90's, RR down and not as labored, color is better. Leslie, thank you so much for your post.

[dorimar]

Good job Limabean! Always it's the nurse who knows something is wrong before the doc.

Doris

[Suesquatch]

I learn so much from you guys. I can't comment intelligently about what's going on because I don't know enough but man, you nailed it! You thought it was a bleed in your first post and it was.

[Indy]

Thanks to your diligence, she didn't bleed to death and didn't manage to go into respiratory failure either. Good nurse! By the way, respiratory failure can cause a heart attack... found that out the hard way, poor lady lived though!

[prmenrs]

Lesson for today: troponin test! Thanks for making me look that up! (I guess I don't have to tell you we don't do that in NICU!)