Medical stumper

[Zen APRN]

I am at my wits end with a medical situation with a pt so I thought I would throw it out to the group here for some advice.

I have a pt in a mental health facility who I have a confusing situation with. This is a overweight woman mid 40's with no serious medical history. Doesn't drink or smoke, hx of depression, meds consist of ativan PRN, ambien, and celebrex.

The pt wakes up fine, and then every afternoon around 1-2pm the pt feels out of it. She describes it as a pressured head, exhaustion, sometimes heart races, and just over all malaise.

BS are always stable unless there is a episode of accelerated HR, BS are WNL.

Dr's think pt is just "acting out" for attention but I honestly think there is something more going on here. Even if the pt is engaged in an activity that she is totally engrossed in and loves I can see it come over her from a distance and she struggles to get through the activity. A lot of times she won't tell anyone and it will go undocumented unless a staff member questions her as to if she is "ok".

Can anyone think of what would be the cause of a afternoon transient issue like this? I am just stumped with this one.

Thanks,

Zenny

[morte, LPN, LVN]

food allergy......does this happen at home? i dont see any AD meds listed?

have her hormones been checked? not just female, all of them, esp cortisol?

does she have metabolic syndrome.....has she been worked up for DM? is she perimenapausal (likely, simply by age)

[Zen APRN]

No AD meds, happens anywhere she is so not just a home thing. She is mid 40's so could be peri but still gets regular periods monthly. Drs don't want to do a work up because of insurance issues and other factors so I am trying to piece the issue together to see if I can come up with a good reason as to why this is happening. It's just boggling me that it's like always mid afternoon ya know.

[morte, LPN, LVN]

No AD meds, happens anywhere she is so not just a home thing. She is mid 40's so could be peri but still gets regular periods monthly. Drs don't want to do a work up because of insurance issues and other factors so I am trying to piece the issue together to see if I can come up with a good reason as to why this is happening. It's just boggling me that it's like always mid afternoon ya know.

so she could die of some endocrine disorder......geesh.....have you checked her blood sugar when this happens?

try feeding her a high protein breakfast, no or little carbs....no caffeine.....it can be interesting, but not necessarily in the patients best interest when we are forced into practicing medicine (on paper)...do you or anyone else on the unit, know an endo that you could "pick" their brains, off the record?

[Zen APRN]

Nope, don't know any endo folk (yet!), I will have to check BS when this is all going on. We do check in AM and then again in PM but it's a little tricky getting a accu check to do it mid day during programs when your monitoring everyone. I'm not there during breakfast but I can talk to dietary. Our unit is a mental health unit so not a lot of resources for things like endo - that would be an outside consult which of course would have to be OK'd by the Dr. Our coffee is decaf and while that still has trace amounts of caffeine there is not way a mental health pt is going to lay off that (they can't smoke). I will do some research on the endo side of things to see what I can dig up. I just don't even know how to word the issue for searching the internet which makes it hard. It's like a increased pressure feeling with malaise?? Thanks for all the feedback... BTW did I mention I am looking for a new job hahaha.....

[morte, LPN, LVN]

this is really frustrating....this is what happens though, when a person isnt fully worked up medically..... if you can get that BS when it is happening you may have your answer/ammunition for further work up.

[Whispera, MSN, RN]

You say the patient has a history of depression. What is she hospitalized for now? Is depression her diagnosis? If so, she isn't on any antidepression medications??

That being said, if she IS on an antidepression medication, maybe the symptoms are related to that medication. Or, is the timing at all related to when she takes her prn Ativan?

Maybe she's not an "afternoon person," and just needs downtime then?

Is she needing coffee? If she is used to having caffeine throughout the day and doesn't get it, that could account for the symptoms you're mentioning.

[Zen APRN]

Yes it's a mental health facility, no she is not on AD meds (at her choice), and she doesn't have a issue with afternoons (already went through that with her), and she was never a big coffee drinker stating 1 -3 cups a week, now drinks same or less in decaf and stats does it more because it's a social thing there in the mornings vs need.

I can't change the way the things are run at this facility believe me many of us have tried and failed many times over. I can just do the best I can do for this patient and exhaust all resources I have such as this forum to try to figure out all angles of this issue. It could just be a psych issue but something in my gut is saying other wise and I want to just make sure I am doing all I can with regards to this.

[morte, LPN, LVN]

Yes it's a mental health facility, no she is not on AD meds (at her choice), and she doesn't have a issue with afternoons (already went through that with her), and she was never a big coffee drinker stating 1 -3 cups a week, now drinks same or less in decaf and stats does it more because it's a social thing there in the mornings vs need.

I can't change the way the things are run at this facility believe me many of us have tried and failed many times over. I can just do the best I can do for this patient and exhaust all resources I have such as this forum to try to figure out all angles of this issue. It could just be a psych issue but something in my gut is saying other wise and I want to just make sure I am doing all I can with regards to this.

thank you

[Whispera, MSN, RN]

...always pay attention to what your gut is saying--it's usually correct...

[Orca, ADN, ASN, RN]

Have you gotten a blood ammonia level on her? I had a male patient on an adult MH unit once who had an undiagnosed liver problem. He would be sitting in a chair and he would suddenly just be completely out of it. Just as mysteriously, he would come out of it and seem completely normal. His blood ammonia level was off the scale.

The timing of your patient's issues, and the consistency of the timing, seems suggestive of an issue with her blood glucose. An A1C might also be prudent.

[stevefl]

How about a reaction to Celebrex?

Steve