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

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." Specialties Critical Case Study

Updated:  

You are reading page 3 of Case Study(CSI): Stomach flu? Anxiety? What's Going on Here?

JKL33

6,777 Posts

12 hours 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.

We asked for an EKG.

Dxs are submitted as instructed in the OP. So they would not have been posted here.

Guest219794

2,453 Posts

On 11/21/2019 at 10:20 PM, JKL33 said:

We asked for an EKG.

Dxs are submitted as instructed in the OP. So they would not have been posted here.

Apparently I am bad at following instructions.

nursej22, MSN, RN

3,820 Posts

Specializes in Public Health, TB.

And...are there any updates? Did the patient under go any further tests or procedures? Inquiring minds want to know?

I'm just a nursing student but I would ask for serial EKGs and trops (x3) and see how they trend, give Zofran and check for edema (HTN? vs HF), listen to lungs (L HF), draw the rainbow (coag, lytes, CBC). No fever IIRC but an abdominal exam to check for tenderness or signs of appendicitis.

Patient Safety Columnist / Educator

SafetyNurse1968, ADN, BSN, MSN, PhD

61 Articles; 526 Posts

Specializes in Oncology, Home Health, Patient Safety.
6 minutes ago, harvestmoon said:

I'm just a nursing student but I would ask for serial EKGs and trops (x3) and see how they trend, give Zofran and check for edema (HTN? vs HF), listen to lungs (L HF), draw the rainbow (coag, lytes, CBC). No fever IIRC but an abdominal exam to check for tenderness or signs of appendicitis.

Nice job nursing student! Scroll up and you'll see the results for the EKG, troponin (only a single time point) and lung sounds as well as other lab values. Her abdominal exam is negative and I have to say from experience that Zofran is an amazing drug that we give in the hospital to folks with chemotherapy induced nausea and vomiting, but I've never seen it prescribed for nausea in an outpatient setting - would love to hear from others on this? I believe it is extremely expensive (which is really too bad, because it works wonders).

51 minutes ago, nursej22 said:

And...are there any updates? Did the patient under go any further tests or procedures? Inquiring minds want to know?

It's coming! I'll post an update on Monday - going to let a few more folks get in on the fun before I give you more clues. Thanks for your patience - I'm following all comments closely ?

OMG I'm an idiot. I thought she had come to UC, not PCP. thanks...

ok, i just read over the presentation again and the labs and am missing the thyroid (due to presentation wide eyes and tachy) and liver panel (due to death and drinking). but most likely (and again, I'm only midway through nursing and few of those drugs ping for me but if she is noncompliant with lipid drugs she likely hasn't OD on her meds unless purposely) after the elevated troponin maybe get a BNP due to the PND/orthopnea described and check for JVD or other HF signs and turf her to UC or EC. Elevated toponin + tachy + diaphoresis + EKG changes (forgot if Ca was okay but I don't remember that lab sticking out) = ED visit with cardiac rule out.

nursej22, MSN, RN

3,820 Posts

Specializes in Public Health, TB.

Our health officer has prescribed Zofran for nausea related to rifampin, with good results. The client takes it 1/2 prior to rifampin, which is best absorbed on an empty stomach. An oral surgeon recently prescribed it for my husband to take prior to his narcotic, with good effect. I think it is best for nausea prevention rather actual nausea and vomiting.

10 hours ago, SafetyNurse1968 said:

I have to say from experience that Zofran is an amazing drug that we give in the hospital to folks with chemotherapy induced nausea and vomiting, but I've never seen it prescribed for nausea in an outpatient setting - would love to hear from others on this? I believe it is extremely expensive (which is really too bad, because it works wonders).

So in clinicals (so far just TCU, next semester we do acute care) I see Zofran all the time FWIW. I"m in the USA midwest. It is used prophylatically I think but when I had hyperemesis with my last pregnancy it did make a difference. So I have now been exposed to have a lack of med knowledge. ?

Patient Safety Columnist / Educator

SafetyNurse1968, ADN, BSN, MSN, PhD

61 Articles; 526 Posts

Specializes in Oncology, Home Health, Patient Safety.
On 11/23/2019 at 9:42 AM, harvestmoon said:

So in clinicals (so far just TCU, next semester we do acute care) I see Zofran all the time FWIW. I"m in the USA midwest. It is used prophylatically I think but when I had hyperemesis with my last pregnancy it did make a difference. So I have now been exposed to have a lack of med knowledge. ?

That is fantastic news about the Zofran. About your lack of med knowledge (?)- I think you are doing a great job of being open minded and reflective - two important characteristics of a safe nurse.

Patient Safety Columnist / Educator

SafetyNurse1968, ADN, BSN, MSN, PhD

61 Articles; 526 Posts

Specializes in Oncology, Home Health, Patient Safety.
42 minutes ago, harvestmoon said:

OMG I'm an idiot. I thought she had come to UC, not PCP. thanks...

ok, i just read over the presentation again and the labs and am missing the thyroid (due to presentation wide eyes and tachy) and liver panel (due to death and drinking). but most likely (and again, I'm only midway through nursing and few of those drugs ping for me but if she is noncompliant with lipid drugs she likely hasn't OD on her meds unless purposely) after the elevated troponin maybe get a BNP due to the PND/orthopnea described and check for JVD or other HF signs and turf her to UC or EC. Elevated toponin + tachy + diaphoresis + EKG changes (forgot if Ca was okay but I don't remember that lab sticking out) = ED visit with cardiac rule out.

Thyroid and liver panels are WNL - the other results are in the thread, but I'll repeat - compliant with medications lately, Calcium was normal (back in the day, we had to make a special request to get calcium added to the BMP - is that still true in places?) BNP (brain natriuretic peptide - elevated in heart failure)- is WNL for A.W.

Patient Safety Columnist / Educator

SafetyNurse1968, ADN, BSN, MSN, PhD

61 Articles; 526 Posts

Specializes in Oncology, Home Health, Patient Safety.

UPDATE! I'll repost all the additional data since the ORIGINAL POST (OP). PLUS some extra info you didn't ask for:

REMEMBER: DON’T POST THE ANSWER HERE!

Ask questions and I’ll give you more information.

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)

Family History (no one asked for this!):

  • Mother died from breast cancer at age 79
  • Father died from myocardial infarction at age 55, had DM
  • Son died in combat at age 24
  • Daughter age 40 diagnosed with pre-hypertension and pre-diabetes, son age 38 alive and well
  • One sister, age 62 alive and well, one brother age 60 with HTN
  • Grandparents “may have had heart disease”

Social History (you asked for alcohol use, but not the rest...):

  • Born in Tulsa, Oklahoma, the youngest of three children.
  • Lives in Santa Monica, California with husband
  • Christian Scientist
  • Runs a non-profit and husband is a writer
  • Drinks “one glass of wine” per day,
  • Smoked half-pack per day for ten years, quit 5 years ago
  • Denies drug use

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

Allergies: NKA

Review of Systems [only abnormal findings are presented]: THIS IS NEW

  • Skin: cool, diaphoretic
  • Slight basilar inspiratory crackles with auscultation
  • Tachycardia with occasional premature beat
  • Soft S4
  • Distinct bruit over left femoral artery

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%

UPDATE

Ms. W. began to experience burning and choking pain in throat, and her jaw started to hurt with pain 9/10. The patient was transported to the ED with suspected heart attack. En route she was placed on nasal cannulae and IV fluids were started. She received ASA 325 mg po and 2 mg/IV morphine. Pain eased slightly to 8/10. Pain unrelieved by 3 SL nitroglycerin tablets.

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

Imaging: Chest X-ray shows bilateral mild pulmonary edema (<10% lung fields) without pleural disease or widening of mediastinum.

Go to the ADMIN HELP DESK and post a specific diagnosis - PLEASE DON'T POST HERE! What you CAN post here is: did anything about the update confirm or refute your initial ideas? Was anything surprising? Was there any data you wish you'd asked for?

On Saturday I'll post the FINAL ANSWER!

Specializes in Family Nurse Practitioner.

LV wall motion study, LV ejection fraction, echo results, lower extremity edema?, aortic ultrasound?