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Case Study(CSI): Stomach flu? Anxiety? What’s Going on Here?

Is this a case of the Stomach Flu? Anxiety? What is it?

Nurses General Nursing Article CSI   posted

SafetyNurse1968 specializes in Oncology, Home Health, Patient Safety.

A new case study in which the patient, A.W. a 65-year-old African American woman presents to her primary care clinic with unspecified complaints. She told the scheduler, “Something’s just not right. I want to come in and talk about it.”

Case Study(CSI): Stomach flu? Anxiety? What’s Going on Here?
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If you think you know the correct diagnosis for this Case Study (CSI)...

Do not post the answer here.

Instead, post your answer in the Admin Help Desk. We don't want to spoil it for others who are late in joining us. In a few days, after the diagnosis is posted, Admins will announce the names of those who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You can ask questions and comments below.


Chief Complaint

“My son died a month ago. He was stationed in Afghanistan. I think I’m still in shock. For the last few weeks I haven’t slept well. I keep waking up in the middle of the night, my heart pounding, out of breath, and now on top of that I’ve been feeling nauseated. I even threw up yesterday. I wonder if I have the stomach flu. I’m just praying I don’t have another migraine coming on.”

History of Present Illness

A.W. began to experience shortness of breath and racing heart approximately two weeks ago, primarily at night. Nausea began two days ago with two episodes of emesis yesterday. Admits to burning pain in her throat that she attributes to heartburn. Ms. W. has been depressed and anxious since learning of her youngest son’s death. Ms. W. states she has been feeling more tired than usual, but attributes it to lack of sleep and stress over her son’s death. Most recent migraine was over a month ago.

General Appearance

Looks anxious. Eyes wide, blinks a lot, shoulders tense, diaphoretic, occasionally rubs stomach just under sternum. Pt appears female, skin is brown in color, appears stated age, looks slightly overweight with weight carried around the middle.

Okay super sleuths, what’s going on here? What information do you need? What would you do first? What labs do you want? What other diagnostic tests should we run? Ask me some questions!

REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is also a mother of four who loves to write so much that she would probably starve if her phone didn’t remind her to take a break. Her work experiences as a hospital nurse make it easy to skip using the bathroom to get in just a few more minutes on the computer. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com. You can also get free Continuing Education at www.safetyfirstnursing.com. In the guise of Safety Nurse, she is sending a young Haitian woman to nursing school and you can learn more about that adventure: https://www.gofundme.com/rose-goes-to-nursing-school

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I’d like to start with a current set of vitals along with an EKG and CBC, BMP, and cardiac enzymes please.

nursej22, MSN, RN

Specializes in med/surg,CV.

What is her past medical history? Is she taking any medications or supplements?

Has she taken any steps to reduce anxiety? Does she drink alcohol, and if so, has her intake changed?

Has she been febrile? What did the vomit look like? Has she had a cough? Any findings on her abdominal exam? Where else is she having pain?

Can we make the BMP a CMP? Let's do a UA and a Utox too.

Would someone be able to educate me on why an LDH would or would not be useful here?

😳

One 12-lead EKG please.

Lots of other info I would like to know (and another diagnosis in mind), but...

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety.

On 11/19/2019 at 8:24 PM, RNDarling said:

I’d like to start with a current set of vitals along with an EKG and CBC, BMP, and cardiac enzymes please.

Thank you for reading and commenting! Here are the pertinent labs and vital signs:

Vital signs:

BP 160/98 RA sitting

HR 105

RR 18

T 98.2oF

HT 5’6”

WT 170 lbs

BMI 27.4

Laboratory Test Results:

Na 133 meg/L

K 4.3 meq/L

Cl 101

HCO3

BUN 14 mg/dL

Cr 0.9 mg/dL

Glucose, fasting 264 mg/dL

Mg 1.9

PO4 2.3

Cholesterol 213

Triglycerides 174

LDL 143

HDL 34

CPK 99 IU/L

CK-MB 6.3 IU/L

Troponin I 0.3 ng/mL

Hb 12.2 g/dL

Hct 40%

WBC 4,900/mm3

Plt 267,000/mm3

HbA1c 8.7%

Arterial Blood Gas

pH 7.42

PaO2 90 mm

PaCO2 34 mm

SaO2 96.5%

On 11/20/2019 at 8:32 AM, JKL33 said:

😳

One 12-lead EKG please.

Lots of other info I would like to know (and another diagnosis in mind), but...

You got it (and thanks for reading and asking!)

Electrocardiogram: 4 mm ST segment elevation in leads V2-V6

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety.

On 11/19/2019 at 10:10 PM, nursej22 said:

What is her past medical history? Is she taking any medications or supplements?

Has she taken any steps to reduce anxiety? Does she drink alcohol, and if so, has her intake changed?

Ya'll ask good questions!

Past Medical History:

Type 2 DM X 5 years

Migraine with aura X 25 years

Hypertriglyceridemia

HTN X 12 years (poorly controlled, poor patient compliance)

Medications:

Amlodipine 5 mg po QPM

Glyburide 10 mg po QAM, 5 mg po QPM

EC ASA 325 mg po QD

Gemfibrozil 600 mg po BID

Terazosin 1 mg ph HS

Metoclopramide 10 mg PRN nausea related to migraine

Imitrex 25 mg PRN migraine pain

On 11/20/2019 at 6:57 AM, CommunityRNBSN said:

Thyroid panel

All normal, but good question.

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety.

11 hours ago, Lulu Belle said:

Has she been febrile? What did the vomit look like? Has she had a cough? Any findings on her abdominal exam? Where else is she having pain?

Can we make the BMP a CMP? Let's do a UA and a Utox too.

Would someone be able to educate me on why an LDH would or would not be useful here?

I posted the lab results - look at those and see if that gives you a clue about the LDH. No fever, vomit looked like partially digested breakfast, no cough.

Negative findings on abdominal exam. No other pain.

UA and Utox normal.

I forgot one:

she drinks "one glass of wine" per day (she didn't mention the SIZE of the glass) 🙂

When is the last time she took her meds? and how many pills did she take?

FNPDreams, MSN, APRN, NP

Specializes in Family Nurse Practitioner.

Check cardiac echo & angio if indicated. Have posted a suggested dx in the Admin section.

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety.

1 hour ago, FNPDreams said:

Check cardiac echo & angio if indicated. Have posted a suggested dx in the Admin section.

FNPdreams - I'll post those results soon. We're experimenting with the format to try to make this the most fun for everyone. Stay tuned!

3 hours ago, Meul_20 said:

When is the last time she took her meds? and how many pills did she take?

Oh that's a great question and gives me an idea for a future CSI. She's taking her medications as ordered, on schedule. No PRN meds since her last migraine was a month ago.

On 11/20/2019 at 9:56 AM, SafetyNurse1968 said:

Thank you for reading and commenting! Here are the pertinent labs and vital signs:

Vital signs:

BP 160/98 RA sitting

HR 105

RR 18

T 98.2oF

HT 5’6”

WT 170 lbs

BMI 27.4

Laboratory Test Results:

Na 133 meg/L

K 4.3 meq/L

Cl 101

HCO3

BUN 14 mg/dL

Cr 0.9 mg/dL

Glucose, fasting 264 mg/dL

Mg 1.9

PO4 2.3

Cholesterol 213

Triglycerides 174

LDL 143

HDL 34

CPK 99 IU/L

CK-MB 6.3 IU/L

Troponin I 0.3 ng/mL

Hb 12.2 g/dL

Hct 40%

WBC 4,900/mm3

Plt 267,000/mm3

HbA1c 8.7%

Arterial Blood Gas

pH 7.42

PaO2 90 mm

PaCO2 34 mm

SaO2 96.5%

You got it (and thanks for reading and asking!)

Electrocardiogram: 4 mm ST segment elevation in leads V2-V6

Well?

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety.

On 11/20/2019 at 6:13 PM, hherrn said:

Well?

I'm sorry, I don't have an actual ECG I can send you...Only the description: 4 mm ST segment elevation in leads V2-V6. Also there's tachycardia, and an occasional premature beat.

I hope that will work for you!

This patient is a walking advertisement for an atypical MI, and had ST elevation in multiple contiguous leads. I am not clear why she isn't on the cath table.

Also- the trop- there are different scales. Our cut off is 0.045, so that trop would be positive.

Am I misreading something here?

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety.

On 11/20/2019 at 7:14 PM, hherrn said:

This patient is a walking advertisement for an atypical MI, and had ST elevation in multiple contiguous leads. I am not clear why she isn't on the cath table.

Also- the trop- there are different scales. Our cut off is 0.045, so that trop would be positive.

Am I misreading something here?

I’m not sure what you mean by missing something, it’s just supposed to be for fun. It sounds like your level of cardiac diagnostic skills is potentially higher than mine.

The reason I asked if I missed something is-

Even without the history, ST elevation is the hallmark sign of an MI. Chest pain, nausea and palpitations are hallmark symptoms. While there can be other causes, none seem obvious.

65 y/o overweight female experiencing high stress levels with chest pain, palpitations and nausea with ST elevation is a STEMI, barring any other convincing explanation. The elevation could be a repolarization abnormality, but nothing points that way. The trop is a bit confusing- there are different reference scales- Absolutely positive on 1, negative on the other.

So- since nobody else offered STEMI on this pt with ST elevation and MI symptoms, I thought maybe I was missing something.

Agree with a previous request for an echo.

Where I work, a patient with pain/symptoms that are plausibly cardiac in nature and substantial st elevations on 12 lead ecg would likely be whisked away to the cath lab, even if the overall picture suggests... something else. Where is that echo tech anyway?

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety.

54 minutes ago, hherrn said:

The reason I asked if I missed something is-

Even without the history, ST elevation is the hallmark sign of an MI. Chest pain, nausea and palpitations are hallmark symptoms. While there can be other causes, none seem obvious.

65 y/o overweight female experiencing high stress levels with chest pain, palpitations and nausea with ST elevation is a STEMI, barring any other convincing explanation. The elevation could be a repolarization abnormality, but nothing points that way. The trop is a bit confusing- there are different reference scales- Absolutely positive on 1, negative on the other.

So- since nobody else offered STEMI on this pt with ST elevation and MI symptoms, I thought maybe I was missing something.

Oh I see now why you were confused, we’re actually asking folks to not post their guesses here but to put them on the admin site

Got it.

No guess here.

Send this PT to the cath lab, let me know how it works out.

Unless there is an interpretation of this EKG showing an explanation for ST elevation other than MI, she needs a cath and probably a stent.

OTOH, if the 0.3 trop is negative, and the ST elevation is read by a qualified clinician as early repolarization, or something else non-clinical, we are back to guessing.

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