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 have 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.
Background History
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.
Presentation / CC
Kate presents 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.
Social History
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.
Assessment
Subjective complaints: "Extreme chest pain, having a hard time breathing"
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 tachypneic, lungs clear to auscultation except for faint wheezing in bilateral bases. Able to speak in full sentences.
Skin: Very cyanotic appearing throughout the entire body, but notably in bilateral hands and periorally. Skin intact but hyperpigmented and indurated in many areas, particularly in arms and legs.
Vital Signs
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
What would your first steps as a clinic nurse be?
What history would you need?
What testing would you anticipate being performed?
Posting from my phone, but wanted to let everyone know you're all largely right. This case was complicated and a bit baffling because she had both pericarditis with an associated pericardial effusion AND methemoglobinemia. Two major acute conditions! I'll post more details later.
The patient continues to be immunosuppressed related to functional asplenia due to transplant, continued systemic immunosuppression for control of her chronic GVHD symptoms, and intermittent steroid use for worsening GVHD flares. As such, she requires PCP prophylaxis and due to intolerance was on Dapsone for this purpose- a drug known to increase risk for methemoglobinemia. She was tolerating this well in and of itself, but then received Novocaine for the dental extractions and used Orajel (benzocaine) at home for pain management. The combination lead to the methemoglobinemia.
The methemoglobinemia was confirmed as a moderate case via the potassium cyanide test.
Echocardiogram showed the pericardial effusion, mild mitral valve regurgitation, and an ejection fraction of 60%.
Given all of these issues, what treatment would you anticipate? How would response to therapy be monitored?
skoolrn, BSN, MSN, RN
99 Posts
I think once they see brownish blood it's a dead giveaway (No pun intended)! Now what's the cause?