Racking my brain for this 14 year old patient, can't get her case off my mind, help?

Nurses General Nursing

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Specializes in Psychiatric.

I work in an acute inpatient Mental Health hospital and last night I was on the Adolescent Unit and this case caught my and the Charge RN's eyes.

14 year old African American female, sickle cell trait, normal weight, normal ECG, low MCH &MCV, high plat, BP 150/100 but seesawing to 139/90 at times usually hovering around 150/100, Pulse between 90-115, low creat at 0.62, high albumin at 5, normal I&O, denying flank pain, back pain, strange urine color, no peripheral edema, no congestion, isolative, quiet, flat affect, focused on her blood pressure, but history of depression and SI. Fam history high for hypertension and she confirms diet high in salt and fat at home although it had been 48 hours since her last meal there. She seems asymptomatic as far as her subjective disclosure is concerned but I can't get over it. I notified the Medical on call and he will see her today but as with many cases in Psych hospitals, if no symptoms, no problem. I'm terrified this girl will stroke out on me or go into kidney failure from a partial or full on crisis (known to happen with trait even) and we weren't proactive enough. I expressed assertively how concerned I was about her and that it just didn't feel right and I was needing to go with my gut that this kid should not have persistent blood pressures with diastolic that ******* high. Her electrolytes were all normal and WBC and RBC counts normal. I'm stumped any ideas?

Specializes in Psychiatric.

sorry I should clarify, she's denying strange urine color, I hadn't been able to observe it.

Specializes in Acute Care Cardiac, Education, Prof Practice.

Unvoiced pain, stress, inappropriate cuff size?

Specializes in Psychiatric.

As far as cuff size we tried multiple machines and stuck with manual just to be sure it wasn't a human error or machine error, in fact we had three different people take it about an hour apart just to be sure. She denied pain and I suppose stress could raise your BP to that degree but the labs coupled with the strange BP for a normal weight female is what has me stumped. Thanks for answering :D

Specializes in ICU, Telemetry.

Pheochromocytoma? I've seen those patients before, and they usually have a very strange affect (flat to manic, sometimes misdiagnosed with anxiety disorders which resolve after surgical removal/treatment). We had one guy, he'd come in looking like he was having absence seizures, and it was because his BP would shoot through the roof. Did anybody get a 24hr urine? (note: labetalol can mess up that lab result). Just an idea.

Specializes in PICU, ICU, Hospice, Mgmt, DON.

I guess I am a little confused...what was her actual admission diagnosis for axis 1? was she actually depressed? I didn't quite get that, just that she was isolative and flat with a hx of depression. Did they start her on Ivf for hydration for the sickle cell? or any diuretics? Was this a Psych admit or a Med admit or both?

Also, what, if any meds did she come in on?

Specializes in Hospice.

Seems like the priority would be to rx the bp without exacerbating either the ss trait or the psych issue ... good luck and let us know what happens. Hope the girl is ok.

pheochromocytoma? i've seen those patients before, and they usually have a very strange affect (flat to manic, sometimes misdiagnosed with anxiety disorders which resolve after surgical removal/treatment). we had one guy, he'd come in looking like he was having absence seizures, and it was because his bp would shoot through the roof. did anybody get a 24hr urine? (note: labetolol can mess up that lab result). just an idea.

ding-ding-ding! we have a winnah! (anyone care to place bets on the side?)

Specializes in OB, Med/Surg, Ortho, ICU.
ding-ding-ding! we have a winnah! (anyone care to place bets on the side?)

i'm with you on this one! sounds like it to me, too. may have to get a visual on that urine.

Specializes in Psychiatric.

To answer a few questions this is a Psych hosp only axis one is depression and SI w plan r/o Ptsd. Med doc started hctz 12.5 qam but no further testing ordered at this point. I put her on strict I & O with RN to assess hat contents. If bp doesn't respond well I am going to request either tx to children hospital or imaging of kidneys pancreas and aldosterone/ cortisol levels. She was on cal count too for no appetite so phyochromocytoma could be poss however does that explain low creat and high albumin? I will keep you guys posted.

thanks!

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

I agree, it could be a pheo......sickle crisis? Maybe. How about just plain aggitation? New admit, SI and wanting to leave.......I'd give her some mild sedation/anti-anxiety before I'd get a CT scan. The numers are off but not outrageous enough to cause me alarm right now....:)

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