Lorita Marino Ihuman Acute Onset Dyspnea And Near Syncope

Lorita Marino Ihuman Acute Onset Dyspnea And Near Syncope

Reason for encounter

Shortness of breath (SOB) and near syncope

History of Present illness (HPI)

A 64-year old female, Lorita Marino presents in the ED for evaluation of acute-onset SOB and a near syncope episode. The SOB begun few hours ago while she was washing dishes when she sat down but it wouldn’t go away before her husband called 9-1-1. She is short of breath when lying down, the SOB is constant, worsens with movement and has no relieving factors. She reports an associated unproductive cough, mild lightheadedness, and unintentional loss of 5 pounds since her knee surgery 6 weeks ago. She denies contact with other sick people. 6 weeks ago, she underwent a right knee replacement surgery.

Physical Exam

1. Cognitive status
2. Blood pressure
3. Pulse
4. Respiration
5. Temperatures
6. SPO2
7. Orthostatic blood pressure
8. Inspect skin overall
9. Inspect eyes
10. Inspect mouth/pharynx
11. Measure JVP (jugular venous pressure)
12.  Auscultate heart
13. Palpate for PMI(Point of maximal impact)
14. Visual inspection-anterior & posterior chest
15. Auscultate lungs
16. Palpate anterior and posterior chest
17. Percuss anterior and posterior chest
18. Palpate abdomen
19. Visual inspection extremities
20. Palpate extremities

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Case Problem Statement 

Mrs. Marino is a 64-year old woman who presents with acute-onset severe dyspnea, non-productive cough, low-grade fever, and presyncopal; symptoms. She is hypoxic (O2 saturation 90% on room air), has a normal heart and lung exam, but has right leg edema and calf tenderness. Of note is a right knee replacement 6 weeks prior and a PMH significant for obesity, DM, HTN, 2PPD smoking habit and a sedentary lifestyle since surgery. She has a family history of CAD.

Review of Systems (ROS)

General: patient reports an unintentional loss of 5 pounds in the past 6 weeks,   denies fatigue, denies chills, fevers, or sore throat.

HEENT/Neck: patient denies headache, trauma to head, dizziness, pain or ringing in ears, abnormal ear discharge, difficulty opening or closing  the jaw, hoarseness, loss of taste, denies recurrent nosebleeds, nasal discharge, or loss of smell. Neck: denies pain with movement, swelling or lump in neck (front or back).

Cardiovascular: patient denies chest pain, palpitations, chest pressure, discomfort, history of murmurs, swelling in face, upper or lower extremities.

Gastrointestinal: patient denies nausea, vomiting, diarrhea, constipation, black sticky tarry stools, denies changes in appetite, abdominal pain/cramping.

Genitourinary: patient denies frequency, urgency, lower back pain, flank pain, foul odor in urine, or blood in urine.

Musculoskeletal:  patient always has swelling in her legs

Neurologic: patient acknowledges feeling lightheaded, denies tingling/numbness in face, upper or lower extremities, denies loss of memory, headaches, stroke-like symptoms, fainting, dizziness or loss of consciousness (LOC). Integumentary/Breast: patient denies rashes, open sores or wounds on trunk, lower or upper extremities, denies excessive sweating or itching in armpits, feet, or palms of hand.

Psychiatric: patient denies hallucinations (visual or auditory), denies feeling blue or sad, denies wanting to inflict self-harm, denies suicidal/homicidal ideations.

Endocrine: patient denies dry/flakey skin on legs and hands, denies increased urination, excessive thirst, excess growth or loss of hair on arms, face, and legs. Denies heat/cold intolerance, hyperthyroidism or hypothyroidism.

Hematologic/Lymphatic: patient denies cold or blue lips, hands or feet, denies feeling chilly often, denies anemia (familial or self-history), denies lack of energy, spontaneous bleeding or bruising.

Allergic/Immunologic: patient denies known/unknown food, medication, or environmental allergies.

Past Medical History: hypertension (HTN), diabetes (DM), osteoarthritis (OA), underwent a knee replacement surgery 6 weeks ago.

Hospitalizations/Surgeries: underwent a knee replacement surgery 6 weeks ago.

Preventive Health: uptodate

Medications: Lisinopril 10mg daily, hydrochlorothiazide 25mg daily, metformin XR 750mg 2 tablets daily.

Allergies: patient denies known/unknown food, medication, or environmental allergies.

Social History: Spanish teacher, emigrated from Mexico, consumes 4-5 glasses of wine weekly, denies illicit/recreational drug use, has a history of tobacco smoking for 80 pack years, lives with  husband of 30+years, takes a diet rich in rice, beans, fish, but avoids sweets. She’s physically inactive.

Family History: Father with PMH of heart failure, coronary artery disease (CAD), myocardial infarction at 57 years old.

Mother with a PMH of diabetes mellitus (DM), hypertension (HTN), and cerebrovascular accident (CVA) at 85 years old.

Management Plan

Diagnostic tests

• No additional diagnostic tests are needed

Medications

• Admit
• Close cardiac and vital signs monitoring
• Unfractionated Heparin (UFH) IV bolus 80units/kg IV then infusion 18 units/kg/hr and once the patient stabilizes, to transition to oral anticoagulants (Erythropoulou-Kaltsidou, Alkagiet & Tziomalos, 2020).
• Hold metformin and start insulin 10 units SC once daily with adjustments based on glucose levels.
• 500mL IV normal Saline boluses and reassess for hypotension
• Supplemental oxygen 2-6 L/min oxygen via nasal cannula for hypoxia.

Consults

• Cardiology consult for further evaluation and management.

Client education

• Educate patient about the causes, risk factors, signs & symptoms, management and complications of pulmonary embolism (PE).

• Do not take alcohol or NSAIDs while on anticoagulants as it increases your risk of bleeding (Erythropoulou-Kaltsidou, Alkagiet & Tziomalos, 2020).
• Watch out for signs of bleeding such as easy bruising, dark stools, or prolonged bleeding (Erythropoulou-Kaltsidou, Alkagiet & Tziomalos, 2020).

• Adhere to all medications as prescribed
• Stay hydrated, do not sit for too long, and do mild leg exercises to promote mobility
• Do not take any OTC or herbal drugs without input of a licensed provider to prevent any drug-drug interactions.

Follow-up

• Daily potassium, PT/INR, aPTT an alternate days

• Repeat CTA & Doppler US (Erythropoulou-Kaltsidou, Alkagiet & Tziomalos, 2020).

• Discharge when patient is hemodynamically stable on oral anticoagulants
• Resume oral metformin & lisinopril upon discharge
• PE is likely to recur and presents with chest pain, dyspnea, leg swelling and hemoptysis. Watch out for these symptoms and seek care immediately.

Reference

Erythropoulou-Kaltsidou, A., Alkagiet, S., & Tziomalos, K. (2020). New guidelines for the diagnosis and management of pulmonary embolism: key changes. World Journal of Cardiology, 12(5), 161. https://doi.org/10.4330/wjc.v12.i5.161

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