EM Forum Case #100 "The Forgotten Question!"
by Charlene Babcock Irvin, MD, FACEP
An 82 y/o female presents via EMS with chief complaint of nausea/vomiting/abdominal pain. I am called to triage to evaluate her, where her comments to me are: “Just leave me alone, I don’t want any of this…just let me go!”
Her blood pressure was low at home, but came up to 100/60 after 500 cc NS per EMS. All vital signs are improved now. EMS notes she has been vomiting since her chemotherapy 2 days ago, and is probably dehydrated.
She has a history of recurrent breast CA with mets to the brain, liver, lung and bones. She had the 3rd course of chemotherapy 2 days ago, and has been weak and vomiting since. She can keep down some liquids, but if she eats any food, everything comes up. No Hematemesis or melena or bright red blood per rectum (BRBPR). She does have epigastric pain, which gets better after she vomits. It is described as achy, and is not pleuritic. No fevers, cough, shortness of breath, chest pain, rashes, or problems urinating. She has chronic back pain from mets to the spine. No localized weakness to extremities, just generalized weakness all over. “I’m just wiped out!”
PMH: Breast CA, s/p mastectomy. Now with recurrent disease and widespread mets. She does have HTN, and NIDDM. She also has CHF, and a ‘small heart attack’ years ago. No Lung problems (except the new lung mets). Total abdominal hysterectomy years ago.
ROS: Bowel movements slightly loose, brown. Decreased urination. 20 lb wt loss in last month.
PE: WDWN female, wearing scarf over balding head. Answers questions appropriately.
HR=105, RR=20, BP=105/80, Temp: afebrile. Sat=98% RA.
HEENT: MM slightly dry, otherwise normal (except balding).
Heart: Slight tachycardia. Mastectomy scars.
Abd: Soft, moderate tenderness over the epigastric area. No masses palpated.
Rectal: Unremarkable, Guiac negative.
Neurologic: strength 5/5 upper and lower extremities. No focal findings.
Extremities: Unremarkable except for pretibial edema of +1 bilaterally. Per family, this is less than usual.
She is hydrated some more, labs are sent (potassium is low at 3.0, and Hbg is low at 8.5, BUN is slightly elevated at 28 and Cr. is 1.5, Glucose is 220. Other labs including cardiac enzymes and lactate are normal). Acute abdominal series reveals an ileus. EKG is unchanged. The case is discussed with her primary care physician and her oncologist, and she is admitted. The oncologist thinks it is likely the chemotherapy is causing these complaints. During sign out rounds, the family and patient are resting comfortably, but the patient is asking for another pain shot as the abdominal pain is coming back.
I was in resuscitation finishing my paperwork on another patient, when the nurse wheels a patient in and states, “She just stopped breathing.”
The resident and I move into automatic mode, and set up for intubation while bagging the patient and checking for a pulse. I ask the nurse what happened and she stated the patient was talking with her daughter, made a funny face, and then became unresponsive. The daughter ran out and got some help. When the nurse came in, the patient had agonal respirations, but still had a pulse, so she brought the patient to the resuscitation area.
The patient still had a pulse, and was an easy intubation while I was getting the information from the nurse and getting her hooked up to the monitor. I asked the nurse to find the resident and doctor taking care of the patient.
She looked at me funny, and then said: “This is your patient, the one with the cancer and vomiting!”
I didn’t recognize her without her scarf, and couldn’t believe it was her as I was just talking to her less than 5 minutes earlier! Just then we lost her pulse.
Questions:
1. What are some critical things to do at this point?
2. Should I allow the family in during the resuscitation? What are the pro’s and cons?
3. How often do you see the triad of chest pain, dyspnea, and hemoptysis in patients with a PE?
4. What is the Westermark sign? What is Hampton’s hump?
Click here for answers and to respond
