What's your diagnosis?

Nurses General Nursing

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OK, 56 year old woman presents with weakness, diaphoresis, nausea, diarrhea, and Dyspnea at rest. BP 140/80, pulse thready 80, RR 28, lungs clear, temp 98. Onset of symptoms 20 minutes ago. History, hypothyroid, arthritis, HTN, depression. Meds zoloft, celebrex, levoxyl, atenolol. Recent history of elevated cholesterol 300's per husband, and just started zocor 2 days ago. Random BS 112.

Am I just a paranoid former cardiac nurse? Because the first thing I thought was MI. Women commonly present with symptoms that are atypical. Coupled w the recent elevated cholesterol. Either that, or she is having that atypical weakness caused by the statin meds. I know of one lady who almost was parlyzed, and developed rhabdo after being on it for 2 weeks.

This just happened to my neighbor, and I just sent her 911. She wanted her hubby to drive her, but she was so weak, she could barely walk. I was a little annoyed that the squad didn't call in MICU, and put her on a monitor. They said her vitals were stable, but just to look at her, my gut screamed MI. They even took the oxygen off b/c she didn't feel any better with it on after 10 minutes!

ER nurses especially, I am interested in your input. I encouraged her to get an ekg at the least, b/c if it is MI, she is a good candidate for thrombolyitcs, being that the onset was only 20 minutes ago. This woman is a strong person and no whiner by any means, to see her so pale and weak, well, it's not just gastroenteritis!

What do you think should have been done

Wow, it sounds as if your neighbor has a lot of stress in her life! Sometimes when people refuse to address their feelings, they are turned inward and show up later as physical problems. Angina is a common reaction to stress. Also, I see a lot of us taking it for granted that her VS are stable. I may be wrong, but aren't we supposed to compare current VS to her baseline? Perhaps a HR of 80 is tachy for her if her baseline is 60? After all, her pulse was thready. BP could be elevated as well if BP was well controlled with meds . . . When I do my first home assessment, I always ask the patient if they know what their pulse, BP, HR and temp usually run.

Specializes in ER, PACU, OR.

aussienurse............ good thought? i hadn't thought about the possibility of organophosphate poisoning, which could account for everything hoolihan mentioned! only one way to find out, if she was playing in the garden or orchard........a little atropine!

me

yes aussienurse!! very good thinking...THAT IS CRITICAL THINKING!!!

hoolahan....here (all over florida) there is no such thing as a BLS truck unlees it is strictly for BLS transfers.

FL state requirement all EMT-P's have ACLS...EMT's do not need ACLS (as they are not allowed to do anything advanced)

Actualy, our Medical Director who does our training and puts out our protocols mentions atypical presentation for MI and ladies....

Thankyou, thankyou,

was just a thought, we had a patient present at A&E with the same symptoms, turned out she'd eaten an apple straight from her neighbours tree, he'd sprayed the week before and she didn't wash it before eating it.

Specializes in Med-Surg Nursing.

So Hoolahan,

Keep us posted with how things turn out! I too would have to say probable MI. Let us know!

Specializes in Home Health.

Well, Nadine called me today. Her enzyme level was 1.6, she has no idea what that is, so I am assuming it was troponin, ekg remains abnormal, she is scheduled for a cardiac cath tomorrow. I told her, whatever you do, don't let Dr. R touch you. She told me she asked who was doing the cath, and told the doc a nurse told her not to let him touch her! He told her he no longer works there. (Thank God!)

I also found out her father had a massive MI in his 50's, and stroked out shortly after that, and was gorked essentially for years. Her mother had a huge MI in her 50's, and 2 brothers died from MI in their 50's. So her history is against her.

She cried today, told me their financial status is really shaky, and she really hopes she can make the July craft show, b/c they need the money. Her husband had to do the last show w/o her, so poor thing didn't have anyone in the hospital. But, according to her, she said, I am OK with that, I don't want anyone here, when I am down, I want to be alone, not be ON for everyone. Her son found out, and is hurt that they didn't tell him sooner. Sigh, give mom a break, huh?

I have been doing some reading on line, and have found several cases w borderline enzymes which turned out to be MI, one in particular, the pt had a 90% mid-circumflex lesion.

I'll let you know what the cath shows.

Meanwhile just saw grandmom, d/c from the hospital yesterday, she was all betwixed w her meds. Hospital d/c instructions said cardizem and warfarin, pharmacy said diltiazem and coumadin. Coumadin said "Take as directed" Direction from d/c instruction sheet were the same. :rolleyes: The directions were written in MD's hand like this 1 1/2 tabs MWF 1 tab TTSS. She had NO idea MWF meant monday wed friday. She was soooo upset, I had to give her a 1/2 xanax to calm her down. I filled her mediplanner and said trust me, I did it right. Don't worry for now what to take when, just follow the boxes, it is one with day of week and even times on it. I assured her she will get it eventually, and until she does, I will be there for her. She was so angry and frustrated b/c she didn't understand WHY the pharm would put take as directed and not say what the directions are on the label. It made her feel stupid, and she is not stupid. I tried to explain to her it depends on labs, but she was in such a state that no learning was going to happen. Poor thing. I took her shopping to take her mind off it, after the xanax. Seems like I am doing a lot of cardiac consults lately!

We just had a woman in the nursing home that presented with many of these symptoms and her dx. was....bowel obstruction!.

I can't believe they took the O2 off,:nono: how lame is that?

Specializes in Community Health Nurse.
Originally posted by gilda

We just had a woman in the nursing home that presented with many of these symptoms and her dx. was....bowel obstruction!.

I can't believe they took the O2 off,:nono: how lame is that?

Hi gilda...My very first reaction to her symptoms was bowel obstruction...vagal nerve interference...I have that...only I couldn't explain the symptom of "Dyspnea at rest". :confused:

Several times a year, I somehow manage to have a terrible vagal nerve interference with my bowels causing these very symptoms. I do have DYSPNEA, but only DURING the episode. I think I have some serious bowel problems, but no doctor seems to want to address them as yet. One doctor told me that he had a few soldiers discharged from the Army because of this very thing...so maybe they don't want to deal with this type of issue. I would think giving the patient something to calm the intestines, smooth the stool BEFORE exit, and relax the vagus nerve would go along way in helping. I plan on pursuing this avenue regarding myself come my next doctor appointment because when those vagal episodes happen to me, it is very scary. Sometimes, I think I am going to pass out and die right by the toilet where hubby will find me on the bathroom floor. :eek:

Specializes in ER, PACU, OR.

margaret........ for us 1.6 is +

our norm is 0-1.5, and if it was 1.6, that's a great thing. the higher the tropnin, the more damage there is........ so i think she is ahead now, if that's the peak.

hope everything works out! :)

me

Cheerfuldoer,,

I don't want to be personal, but why don't you try a stool softner

qd. and do you drink enough H2O?

Gilda

MY first thought was ?MI But having seen something similar in my area I thought maybe bowel obstruction, diarrhea being over flow. Anyway good luck and I hope she's improved. neatnurse:

Specializes in Community Health Nurse.
Originally posted by gilda

Cheerfuldoer,,

I don't want to be personal, but why don't you try a stool softner

qd. and do you drink enough H2O?

Gilda

Ahhhh...go ahead Gilda...get personal on me. ;) :chuckle

Yes, I do drink lots and lots of water. Water is my favorite drink! Always has been, always will be as I don't care for sweet or carbonated beverages much. I may have an occasional few sips of Pepsi or Ice Tea or Lemonade when hubby and I go out to dinner, but for the most part, I promote drinking water like Britney Spears promotes drinking Pepsi. :chuckle Also, when I'm having that vagal response with the intestinal tract, I'm NOT constipated but have a serious case of Diarrhea...I'm NEVER straining to have a stool. One does NOT have to have a problem with constipation to have this vagal thingy that I and a lot of other people have...according to my doctor. Thanks for the suggestions though. :)

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