Case study - what would you do?

[Lev]

Mr. Jones is a 42 year old male who arrived via EMS to your hospital's ER with complaints of sudden shortness of breath and sharp 10/10 chest pain radiating to his left shoulder and back. Vital signs on arrival to the room are BP 138/65, HR 127 BPM, RR 36, and SpO2 is 99% on 15L of oxygen via a non rebreather mask. Mr. Jones has no underlying health conditions. He has a slim build and smokes 3/4 pack of cigarettes per day. The MD arrives to the room as the patient rolls in and respiratory therapy is called to the bedside. Mr. Jones in is visible respiratory distress and is using accessory muscles to breath. Mr. Jones is very agitated and states in full sentences that all he needs is some oxygen and insists that he will be fine without having labs drawn or an IV inserted. His family is very surprised at how he is acting. As this patient's nurse, what are your next steps?

[Lev, MSN, RN, NP]

EKG was done which showed sinus tachycardia with no St segment changes or abnormalities. Patient continued to be extremely agitated and was yelling at staff while completely alert and oriented. Family kept trying to convince staff that he was really the "sweetest person" and didn't normally act like this. BPs were done in both arms with equivalent values. Patients lung sounded diminished bilaterally, but more diminished on the left without adventitious breath sounds. No obvious JVD (but kept hob elevated in high fowlers).

[JustBeachyNurse, LPN]

Could be hypoxia confusion secondary to PE or pneumothorax need a chest X-ray. SpO2? agreeable to labs perhaps ABG? Relief with O2? Even SL morphine can help with work of breathing

[emtb2rn, BSN, RN, EMT-B]

How many energy drinks did he have that day?

[blondy2061h, MSN, RN]

EKG was done which showed sinus tachycardia with no St segment changes or abnormalities. Patient continued to be extremely agitated and was yelling at staff while completely alert and oriented. Family kept trying to convince staff that he was really the "sweetest person" and didn't normally act like this. BPs were done in both arms with equivalent values. Patients lung sounded diminished bilaterally but more diminished on the left without adventitious breath sounds. No obvious JVD (but kept hob elevated in high fowlers).[/quote']

Now I'm thinking pneumothorax. Can we go to CT now?

[enuf_already]

With his insistence that he wants nothing but oxygen, is he trying to hide something? Drugs?

Are we assuming cardiac because of the mention of sharp chest and shoulder pain when maybe it could be abdominal with referred pain?

I agree with ruling out a pneumo, PE, and dissecting aneurysm.

What was this guy doing immediately before and a few hours before the pain started?

I'm not an ED nurse and don't play one on TV but am curious to see how this turns out

[michlynn, BSN, RN]

Not optional... based on?

Based on the fact that he appears to be hypoxic and probably not in his right state of mind. They're obviously not going to let this man walk out of the hospital, which seems impossible for him at this point anyways.

He clearly needs an EKG, chest xray/CT, labs - cardiac markers, etc. Obviously a PE or MI will potentially kill him so I would be in there doing everything in my power so get the appropriate tests ordered for this man. Get his family involved if need be.

[Lev, MSN, RN, NP]

What was this guy doing immediately before and a few hours before the pain started?

Patient was at home with no exertion activity prior to sudden onset of symptoms.

[Lev, MSN, RN, NP]

What was this guy doing immediately before and a few hours before the pain started?

Patient was at home with no exertional activity prior to sudden onset of symptoms.

[Lev, MSN, RN, NP]

What was this guy doing immediately before and a few hours before the pain started?

Patient was at home with no exertional activity prior to sudden onset of symptoms.

[icuRNmaggie, BSN, RN]

Synthetic cannabis user?

[Lev, MSN, RN, NP]

Synthetic cannabis user?

No drug use.

[jadelpn, LPN, EMT-B]

1. Spontaneous pneumothorax. Slim build and smoker. Chest X-ray, ABG, set up for chest tube. Agitation secondary to hypoxia.

2. Pulmonary embolism. D-dimer, ABG, PT, PTT, PTINR...If there's disordered bleeding and clotting, a head C/T to r/o infarct/bleed.

3. Along those same lines, any head bump that could have caused a head bleed/concussion, resulting then in a PE? CT/MRI of brain? Causing a seizure--hence the agitation/and full blown panicky hyperventilation?

4. And by "hanging" around the house, does the guy get out much.....meaning is he is sitting about with no leg circulation....again with the PE ?

Full labs, chest xray, ABG, head CT and/or MRI--2 large bore IV's, urine (tox screen, micro) ETOH level, what meds does he take? What energy drinks, "vitamins" herbs powders and/or other does he take?

PMH? Has he recently taken up swimming again, biking with a knee replacement....some other significant PMH?

Good one....thinking out loud (or typing out loud HAHA) but I love this stuff!!