This is a case study of a young woman with a complex medical history presenting with acute chest pain and cyanosis. The case is based on a real patient with details changed to maintain privacy. The case serves as a reminder that there can always be more than initially meets the eye. Specialties Critical Case Study
Updated:
Juan de la Cruz's excellent case studies lately have inspired me to share an interesting one I saw several years ago. The details have been changed to protect privacy, but the foundation of the case is based on a real patient. I hope it's okay that I have borrowed Juan's format.
Kate is a 24-year-old Caucasian female with a history of non-Hodgkin's lymphoma (NHL) originally diagnosed when she was 14 years old. She had an autologous stem cell transplant during her first remission at age 15. She maintained remission for 2 years following this treatment and relapsed at age 17. At age 18 she had an allogeneic transplant from an unrelated donor and has continued with no evidence of disease since. She has had a complicated course following transplant, however, with chronic graft versus host disease of the skin, gut, and mouth.
Kate presents today to the oncology clinic with complaints of mild shortness of breath and substernal chest pain. The shortness of breath began last night and is only mildly worse today. The chest pain, which she rates at a "20 out of 10" began acutely this morning.
Many bone marrow biopsies, lymph node biopsies, and central line placements. Over the course of the last 6 months has had to have several teeth removed, with the latest 2 being removed this week.
Kate has been chronically ill for some time and as such does not work or attend school. She is on disability and lives with her mother and brother. She has a boyfriend for the past 2 months and is sexually active with him. She has a poor relationship with both of her parents. She does not smoke, but drinks "almost every night" and consumes marijuana in "brownie" form as she is worried about the lung effects of smoking it. Kate is well known in the heme-onc clinic due to her chronic condition and her frequent outbursts related to feuds with family and her boyfriend and what she feels are inadequate prescriptions for narcotic pain killers and anxiolytic drugs. She refuses to see many of the providers throughout the hospital.
You are the nurse evaluating Kate in the oncology clinic.
What would your first steps as a clinic nurse be?
What history would you need?
What testing would you anticipate being performed?