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."
"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!
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.
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.
Specializes in Education, Informatics, 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.
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.
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. ?
Specializes in Education, Informatics, 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.
Specializes in Education, Informatics, 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.
Specializes in Education, Informatics, 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?
JKL33
7,043 Posts
We asked for an EKG.
Dxs are submitted as instructed in the OP. So they would not have been posted here.