What would you think if you saw this patient?

[coffeemamaRN]

Just curious to know what other nurses think. To me it sounds obvious, but maybe I'm missing something...

Let's say you have a patient in an outpatient clinic with the following symptoms: he cannot swallow, cannot talk, and is drooling because he cannot swallow properly. He never had problems with swallowing or talking before this. He is in his 20s, and has a history of cancer when he was a child. No facial drooping or other symptoms present. As a nurse, would you recommend:

A)the patient should go to ER immediately for further evaluation, and it is most likely neurological rather than a GI issue

Or

B)the patient should be prescribed robinul and referred to a GI specialist.

To me, A seems obvious. But in this case, the doctor went with B, and I still don't really understand why. Any insights?

[terry53]

Patient cant swallow - therefore cant protect airway- off to ER by EMS please

[KarenMS]

Sounds a bit like homework!

It doesn't sound like a typical nursing school question to me.

[YoutubeTheNP]

Well, I'd go with option C and do an exam. Young patient. A retropharyngeal abscess can present this way, rare diphtheria also, +4 abscessed tonsils. So what was the exam findings? You're really leaving out important stuff

[coffeemamaRN, RN]

Thank you to everyone for your responses, I really appreciate the different perspectives. To me, it seems like all around, the doctor should have referred the patient to ER immediately.

In this case, it was my youngest brother who went through this. The symptoms developed over a couple of weeks. His breathing was not compromised, just his ability to swallow and talk. I did not include the type of cancer he had, but it was a malignant brain tumor at the age of six. He was in remission for all this time until these symptoms occurred. The doctor was aware of his history, yet still prescribed Robinul and referred to GI. After almost two weeks, he went to the GI appointment, who was the one who told them to immediately go to ER.

As to why my parents would take him to the outpatient clinic instead of ER...I don't know. I can only think that maybe it was a certain level of denial in hoping that it was a temporary ailment that would resolve, rather than a return of his cancer. Unfortunately, it was a brain tumor even larger than the one before, and it is terminal. He is on hospice care now.

I guess I'm still trying to come to terms with the whole thing, especially trying to figure out why the doctor would advise my parents the way he did. He is also the same doctor who told them that he no longer needed follow-up CT scans, despite the high risk that his childhood cancer might return. So by the time he had his symptoms, the tumor was too large (plus there were other smaller tumors present). I know that if it were different, it doesn't necessarily mean that my brother would have survived. But I still do not understand the doctor's reasoning behind all this.

Anyway, thanks again for all the responses.

[sunny time]

hospital for sure, sounds like a stroke. even though he is in his 20s . stroke can strike at any time. if the pt is a juvenile diabetic this could happen. The me is a fool and should have his license under scrutiny by a panel of his peers

I hope you charted that you suggested to call an ambulance. cover your own behind because sh#t rolls down hill and falls on the nurse every time. let us start putting the responsibility back on the decision maker not th nurse

[JKL33]

coffeemama, I am so sorry.

Though your brain may know that the 2 weeks' delay from this clinic visit did not change anything, that is no consolation for the devastation of what you and your family are facing. And the follow-up recommendation is another matter entirely.

(((may your days with your brother be special))), there are really no other words.

JKL

[sunny time]

I am sorry for him and you. sounds like a lawsuit. you have one year from the incident. don't let this poor md get away with his poor dianosis

[ComeTogether, LPN]

Go directly to the ER do not pass go, do not collect $200 dollars. I mean, I don't get it. I'd be curious to see how this case turned out. It's not like urgent care facilities typically have intubation equipment, monitors, radiology or stat labs.

[ComeTogether, LPN]

Thank you to everyone for your responses, I really appreciate the different perspectives. To me, it seems like all around, the doctor should have referred the patient to ER immediately.

In this case, it was my youngest brother who went through this. The symptoms developed over a couple of weeks. His breathing was not compromised, just his ability to swallow and talk. I did not include the type of cancer he had, but it was a malignant brain tumor at the age of six. He was in remission for all this time until these symptoms occurred. The doctor was aware of his history, yet still prescribed Robinul and referred to GI. After almost two weeks, he went to the GI appointment, who was the one who told them to immediately go to ER.

As to why my parents would take him to the outpatient clinic instead of ER...I don't know. I can only think that maybe it was a certain level of denial in hoping that it was a temporary ailment that would resolve, rather than a return of his cancer. Unfortunately, it was a brain tumor even larger than the one before, and it is terminal. He is on hospice care now.

I guess I'm still trying to come to terms with the whole thing, especially trying to figure out why the doctor would advise my parents the way he did. He is also the same doctor who told them that he no longer needed follow-up CT scans, despite the high risk that his childhood cancer might return. So by the time he had his symptoms, the tumor was too large (plus there were other smaller tumors present). I know that if it were different, it doesn't necessarily mean that my brother would have survived. But I still do not understand the doctor's reasoning behind all this.

Anyway, thanks again for all the responses.

So sorry to hear this, OP. I don't think the delay in going to the ED would have changed is prognosis, but I know you're all heartbroken over this all.

I'm so sorry, i truly don't know why the doctor wouldn't have called the ambulance right then and there, but he didn't.

For now, be with your brother and when the time comes you can look into this all more deeply.

[Chaya, ASN, RN]

So sorry to hear the result. He and your folks are lucky to have your caring, insights and guidance at this time

[Marisette, BSN, RN]

Thank you for sharing your story. I'm sorry your family is going through this. We have a tendency to wonder what IF we had done something differently, perhaps sought different or better care, we could have prevented the present outcome. It's a heartbreaking and difficult position to be in. Sometimes, the outcome to disease is beyound anyone's control. I'm sure your family did everything they knew and felt they could do for this child. I wish you and your family peace and comfort in knowing this.

[connectchoicecareme]

Patient condition is critical and should be sent to Emergency room immediately for evaluation, adequate Data collection,neurological consult ordered immediately by ED doctor in case patient has CVA,also GI consult is needed,and other test CT SCAN,MRI,XRAY,and some Labwork.

When in doubt ask questions and take appropriate action.

Is the patient on drug?If yes what is he smoking,inhaling,or whatever?

Appropriate Data collection is essential .

Since patient has history of cancer.Is there any indication that the cancer is back?