What's your diagnosis?

live4today, RN · Jun 23, 2002

Immediately thought Hyperthyroidism...thyroid not under control...patient mixing and not taking medications as prescribed...MI also possible...maybe secondary to something else that triggered the response in her... Prayers are with her. :nurse:

hoolahan, ASN, RN · Jun 23, 2002

I never even thought hyperthyroid, good thoughts. Maybe tachycardia and HTN assoc w that were masked by atenolol?

No, psych wise, she is a stable cookie. Mother in a nsg home, guilt feelings, worried about son's marriage falling apart, but if she is anxious, she doesn't share that outwardly, or speak about it to me, or her husband. (He said I had to get you b/c she won't talk to me about it.) Definitely depressed, and zolft seems appropriate.

She thinks they will d/c her tomorrow. Her son came over to wash his car today, he thought she was w his dad at the craft show they were supposed to go to, they are crafters. She said, please don't tell Todd, I don't want him to worry. I said Nadine, the whole neighborhood knows when an ambulance shows up, and everybody is out in their gardens today. If he hears though, it won't be from me. Maybe you should tell him, so he doesn't hear it from someone else first. Nope. Just like her to not want to stress him anymore.

I briefly thought GI bleed, didn't look at the stool to be honest, but I didn't let her go to the BR herself. I said I will stand here w my back turned, but you're not going in alone. (I honestly was afraid she'd go out on the pot, seen a lot of men and women go out during BM, and a few with huge MI's who were puking into an emesis pan while sitting on the bedpan w diarrhea. Too many code browns to leave her alone! The light bothered her eyes, so she wouldn't let me turn the light on, door was cracked for light from hall. But, it didn't smell like GI bleed, at least not a lower GI bleed. Could be.

OK, I called her today. She is in progressive care. She said the cardilogist saw her and said her enzymes didn't look like MI, but EKG showed some "abnormalities." She said he's waiting for the next sets of emzymes to be sure. Then they will do a stress test, etc.

Sat? Are you kidding? NO, no sat. But she did tell me they put the 02 back on when she got into the rig. Sheet, if we can transport a pt on a vent w IABP to CT scan, they should be able to manage a simple 02 tank from porch to ambulance! She didn't have to wear 02 now she said, so her sat is probably good. But right on, what harm would it do to just keep it on???

So, it seems the general consensus is cardiac, but perhaps it's secondary to the thyroid?? I will ask her if they got a level? Wish I could see that 12 lead w my own eyes! Thanks for all the good input, keeps me thinking since I am not in the hospital any more!

CEN35 · Jun 23, 2002

hoolihan,

i only read your first post and nothing else.

12 lead

abd series

abg's

cbc with diff

bmp/hfp/amylase/lipase

tropnin/myoglobin

2 iv sites lge bore

b/p in both arms to attempt to r/o disection/anurysm, until the creatinine and bun return to do a ct of the chest and abdomen.

ntg/sl 0.4 x1

asa325 po

check for pain relief from ntg.

if no pain relief:

possibly go to the maalox/donatol/viscous lido mix and check for relief.

at this point if no relief, go to a ntg drip and mso4, and anti-emtic for the nausea. in the event it is disection or cardiac related, help the pain and get the sbp to about 110mm.

by this time the creatinine and bun should be back, among other labs. if normal, send to ct to r/o ruptured appy/diverticuli and/or cholecystitis.

theory: you have to be able to tie it all together.

rules out:

thyroid storm is out, because of a normal temp and the dyspnea.

ruled out (most likely):

you cannot account for the diarrhea with the cardiac issue.

ruled out:

pe, again a pe does not account for diarrhea.

ruled out:

side effect from the anti-cholesteral med, even with elevated lft's. why? sudden onset!

things that need to be ruled out, that can't be because we currently have no lab results/ct results or plain films:

disection with pending hypovolemia - from hemmorhage in early stage of shock (with the pulse masked by the atenolol), which would contribute to the dyspnea, nausea diaphoresis, weakness and diarrhea if the bleeding is in the retroperatoneal area.

aaa - would contribute to all, again if there was hemmorhaging in the right area.

ruptured diverticuliti - accounting for diarrhea, nausea, pain, weakness, diaphoresis and dyspnea because of a new onset of free air causing hemi elevation of the diaphragm.

least likely: cholecystitis, that may be causing her to feel dyspnic? then it would also be the reason for nausea, no temp, diarrhea andweakened feeling.

let us know what happened?

me

hoolahan, ASN, RN · Jun 23, 2002

w:eek:w Rick, you have blown me away!!

EMTPTORN · Jun 23, 2002

an embolism comes to my mind, but i am a lowly student......speaking for the prehospital side, if my truck had come to your neighbors house hulahan... i would have let you look at the 12 ld that we performed....(providing the pt consented)....twice in the past six months i have treated women (>40 y/o) for c/o abdominal pain and they ended up having mi's......12ld was not conclusive both times, but of course it is not a sure marker, as enzymes are.

one other comment....i don't know what the rescue squad where you live have for protocols or equipment so i can't/won't pass judgement???

my home, ems is pretty agresssive/progressive and with LIBERAL standing protocols...

regards

hoolahan, ASN, RN · Jun 23, 2002

Hi EMTPTORN, welcome, haven't seen you post alot.

PE is a good thought also, most definitely, but when I have seen PE, monitred in hospital, pt is usually tachy as well, but nothing is always textbook.

Wow, a squad that does 12 Leads, now I am impressed, that is AWESOME!!!!!!!! Our usual routine here is cops first, they put on 02, and just watch person, talk to them and relax them if no one else is there, but I was doing that, so they were just admiring the crafts all over Nadine's house. I will say squad was there in under 10 min, cops in 2, but I was very dissappointed in the fact that no mobile ICU rig was called, that is the judegment call of the BLS unit.

Once again, in this case, I truly feel it was ignorance of the fact that woman present in atypical fashion for mi, as you know. Once you have seen it, you don't forget that. Maybe BLS personnel don't have to take ACLS, and I haven't taken it in 2 years, so I am not sure this is included in the material, but I am pretty sure it is, since the AHA really likes to update to latest trends, research, and therapies.

live4today, RN · Jun 23, 2002

Originally posted by hoolahan
OK, 56 year old woman presents with weakness, diaphoresis, nausea, diarrhea, and Dyspnea at rest. BP 140/80, pulse thready 80, RR 28, lungs clear, temp 98. Onset of symptoms 20 minutes ago. History, hypothyroid, arthritis, HTN, depression. Meds zoloft, celebrex, levoxyl, atenolol. Recent history of elevated cholesterol 300's per husband, and just started zocor 2 days ago. Random BS 112. What do you think should have been done

Hoolihan...I was on my way to bed when I got a 'brainfart'...amazing that I still get them :chuckle...Anyhoo...I got to thinking about the symptoms and they made me wonder if the combination of meds she is taking is somehow responsible, especially since she just started taking Zocor two days ago. Zocor alone caused me to have a few of these related symptoms, then you add that to the other medications she is on. Just another thought that came to mind. MI still possible, but labs will tell. :)

Sleepyeyes · Jun 23, 2002

Originally posted by hoolahan
w:eek:w Rick, you have blown me away!!

Rick ROCKS!!

CEN35 · Jun 23, 2002

as i said zocor can be responsible for those s/sx, however..................sudden onset? not!

thats all!

me :)

LilgirlRN, ADN, RN · Jun 23, 2002

No PTE, no tachycardia...this rules out hyperthyroidism too. The diarrhea could be something very simple such as lactose intolerance. Diaphoresis could be jsut because she was vomiting, weakness? vasovagal? but heart rate was too high for that. Perhaps it is something very simple like gastrointeritis, we've definitely admitted 100's of people with that diagnosis. The bad thing about being an ED nurse is that after the patient leaves us, we don't know what happened. Rick is a little more aggressive than I would have been, but then most guys in the ER are. This woman's vs are not bad. She may be diaphoretic, btu I'm chalking that up to nausea. I'm typing as I am thinking so there is no organization to what I am typing. Diverticulitis, nope, she would have pain, definitely not a ruptured one again no pain. My personal feeling on this one is gastrointeritis. She has EKG changes but nothing acute....you can have more than one thing going on in a body at the same time. Sounds like she does have heart disease but that's not the cause of her current difficulty. If she had an aneurysm, she'd be dead by now. If she really wants to know if she has heart disease and how bad it is, tell her not to let them get away with just walking her on the treadmill, she needs to be cathed. If she had hyperthyroidism, and the atenolol was controlling the HR, then she wouldn't have the symptoms associated with tachycardia, ie, weakness because she wasn't tachycardic, but the level does need to be checked. Although she isn't "elderly", when we can't find a reason for the patient to be sick, if she's old and female, it's usually a UTI..ask about that. :) Wendy

Aussienurse2 · Jun 23, 2002

Just my two cents worth, Does she garden?

Only asking because some fertilizers and garden sprays can precipitate the onset of these symptoms ( excessive sweating, diahorria, inc temp,pulse and B.P.) Just a thought....

Whish her all the best, hope she gets well soon.:kiss

mattsmom81 · Jun 23, 2002

Personally I am always 'ruling in' an MI with women with symptoms such as hers...I've had several patients discharged from ER with these types of symptoms disregarded...only to have massive MI's in progress with the thrombolytic window missed.

I'm with ya, Hoolahan and others...better safe than sorry and time is muscle.:). Let us know if she's OK..glad you were there with her! :)