Case Study: Cyanosis
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.Juan de la Cruz's excellent case studies lately has 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 presented 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.
Past Surgical History:
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:
Subjective complaints: "Extreme chest pain, having a hard time breathing"
Temperature 36.5 C, HR 125, RR 22, BP 130/90, O2Sat 79% on room air, 88% on 50% venti mask, 93% on 100% non-rebreather
Neuro: AOx3, moving all extremities, pupils equal and reactive.
CV: Tachycardic, panphasic frictional rub heard when Kate is learning forward, Gr II systolic murmur heard, previously noted
Pulm: Mildly tachypnic, lungs clear to auscultation except for faint wheezing in bilateral bases. Able to speak in full sentences.
Skin: Very cyanotic appearing throughout entire body, but notably in bilateral hands and periorally. Skin intact but hyperpigemented and indurated in many areas, particularly in arms and legs.
What would your first steps as clinic nurse be? What history would you need? What testing would you anticipate being preformed?Last edit by Joe V on Jun 26, '13
About blondy2061h, MSN, RN
blondy2061h has '6' year(s) of experience and specializes in 'oncology'. Joined Jul '08; Posts: 2,662; Likes: 4,346.1Jun 26, '13 by jadelpn GuideI am completely unfamiliar with oncology. But this is very interesting, and will follow the case, as I am intrigued.
But from my experience, this patient has psychiatric issues that are worth looking into. Early trauma of chronic disease can point to a personality d/o, hence the behavioral issues. That she claims she "eats pot" as opposed to smoking it, because she is afraid of lung damage is something worth looking at, as I think perhaps she is smoking something else.
The teeth damage to point of extraction--not sure if this is part of the disease process of her illness, however, again, could point to drug addiction.
It is difficult to say the least to spend a large amount of childhood chronically ill, in remission, then ill again. Long term discharge plan should include some intense therapy.
Is the patient suicidal? Is this an attempt?
Coming from a complete novice, is this a sign that in fact the transplant is failing, that she is no longer in remission, she is in CHF, and also could benefit from being put on some lasix to see if you can get some fluid off.
Otherwise, I am very intrigued. Great case.2Jun 26, '13 by psu_213, BSN, RNI too am not an oncology nurse, so I am unsure how the H/O NHL plays in to the clinical picture. Otherwise, given the CP, friction rub, and recent dental work, I'm thinking pericarditis.
I would be asking the patient if position changes change the quality/quantity of the pain. I would also want an EKG and a chest X-ray (yes, I know I will need a doc's order for those).
Definitely want to hear more!1Jun 26, '13 by skoolrnAdmit to ICU, (needs increasing respiratory support to maintain O2 Sats and cardiac monitoring). May need pressure support or intubation. IV pain control. Chest CT, cardiology consult. Cardiac echo. Lots of labs! Blood gasses. r/o severe anemia, r/o PE, r/o valve issue, r/o pericarditis2Jun 26, '13 by umcRNEKG, chest xray, echo - she could have myocarditis r/t the recent teeth removal, chronic illness and likely weak immune system. Admit to ICU for sure. She could also have a late onset chemo induced cardiomyopathy, either way her heart seems to be struggling. I am not a hemo-onc nurse (I am cardiac) but I believe graft vs host can affect the heart as well, pericardial effusion? I actually had a patient with a massive pericardial effusion caused by his graft vs host and he was quite a long time out from transplant.2Jun 26, '13 by me1989Endocarditis? Hx of recent tooth extraction, are we talking about Osler/Janeway nodes when we mention hyperpigmentation and induration? And I hate to judge, but she may have experimented with injecting some of her narcotics.
Any history of heart disease? You mention the grade two systolic murmur was previously noted. Was an EKG ever done in the past? I have very little experience in oncology, so I don't know if any of her chemotherapies could cause heart damage. Did she take any antibiotics before her extraction?
ICU admit, symptom management, echo, usual labs, blood cultures, Vanco...Last edit by me1989 on Jun 26, '131Jun 27, '13 by SwansonRNAre the teeth extractions r/t the GVHD in the mouth...like does it cause a sicca syndrome?? I only ask because I've seen a young woman with graft vs host who had a similar presentation minus the chest pain and the doctors said something about Sjrogen's when going through diff. Diagnoses. It can cause an interstitial lung disease. Just a thought, though, I agree with the other posters it sounds like more of cardiac issue.0Jun 27, '13 by blondy2061h, MSN, RNExcellent thoughts all around from everybody. The patient does indeed have a significant psychiatric history, including histrionic personality disorder, borderline personality disorder, depression, and generalized anxiety disorder. The patient has been taking paroxetine and seeking counseling over the past 2 years and these symptoms are largely improved, though she still has interpersonal relationship problems. She has consistently denied suicidal ideation, has no previous suicide attempts, and has largely been compliant with her medical plan in recent years.
The dental extractions were indeed related to GVHD of the mouth (in addition to somewhat lacking hygiene). The patient has tooth decay and gum recession related to years of dry and ulcerated mouth. Before the extractions she was premedicated with Amoxicillin 2gm PO 60 minutes prior to appointment.
In clinic blood work, peripheral blood cultures, and an arterial blood gas were drawn. Results as follows:
Chemistries: Na 146, Glucose 129, K 3.6, Mg 1.5, Creat 1, BUN 23, CO2 20, Calcium 9.5, Phos 4.6
CBC: WBC 6.91, Hgb 9.6, Hct 26, Plt: 110, ANC 3.1
ABG: pH 7.47, pO2 74, pCO2 23, HCO3 17. The nurse drawing the ABG noted the arterial blood to be brown tinged in color.
Cardiac: BNP 10, Troponin <0.2, CK MB 2, CPK 75
EKG: Sinus tachycardia with mild ST elevation throughout all leads except aVR, which has mild ST depression
(not actual film, photo credit: Wikipedia)
IV access is attempted 6 times by three different nurses, but Kate has historically poor veins and a temporary triple lumen CVL is placed. Kate complains of feeling chilled after this procedure and a repeat set of vital signs shows that she has a temperature of 38.2 now. She continues to have an O2 sat of 88% on 100% NRB, BP 122/90, HR 130, RR 22.
Intubation is discussed, but Kate does not show signs of increased work of breath, despite the continued cyanosis. She continues to be able to speak in complete sentences, and only states feeling mild to moderately SOB. Kate is given 2mg of morphine, but denies relief of her chest pain. She states, "Only dilaudid, at least 2mg, ever helps my pain, and I need Benadryl with my dilaudid so that I won't get itchy." The 2mg dose of morphine is repeated 30 minutes later and at this time Kate admits mild relief. Kate is admitted to the inpatient blood and marrow transplant unit (BMTU). She is placed on continuous cardiac monitoring and continuous SpO2 monitoring. An echocardiogram is ordered but has not been performed yet.
Kate has no history of other cardiac disease except for mild mitral valve regurgitation diagnosed as a child. Previous echocardiograms have been done related to chemotherapy monitoring and have showed normal ejection fractions and otherwise normal valve function.
What other history is important to obtain? What management would you expect at this point?1Jun 28, '13 by jadelpn GuideI the aterial blood is brown tinged, she doesn't seem to be perfusing well. Would be curious if this is some sort of rejection of the marrow she received from the donor.
I would think that diaressing her would be indicated.
What does her abdomen look like? Does she have acities that needs to be drained?