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Wednesday, March 27, 2013

A Question For You All. . .

Ok, all you experienced docs (ok, fellow nurses too) out there, I have a question for you.

Patient stats:

Male, 45 years old.
Hx of MI and "other cardiac issues" as it was put to me by the doc

Pt presents to ER c/o cough, congestion, body aches, mild nausea, "a little bit of lethargy" x1 week.  Pt states that his chest hurts only when he coughs.

New ER doc orders complete cardiac workup.

EKG normal sinus rhythm, not paced.
All labs come back normal.
Chest x-ray unremarkable.

Question for you guy is:

Was that workup reasonable?  Too much?  Given the information presented, what would you do with this patient?  Admit?  Discharge to follow up with primary doc?  Discharge to follow up with cardiologist?

Please answer in the comments.  I'll tell you what happened with the patient in the comments section after I get some answers. . .


  1. My thoughts:
    Would need more info on & from patient.
    -History, and is diabetes well-controlled or not?
    -Physical exam & VS
    -Recent travel/ill contact history
    -Events surrounding necessity of pacemaker placement

    Others can easily add more ideas
    He's fairly young for MI and 'other cardiac issues'.
    All these should assist in treatment and disposition decisions. Just doing a cardiac workup due to history is not the way to go.

  2. Depends on the doc, of course! (ER RN here) There's MD's that I know I'd roll my eyes at and go "oh boy..." as I'm placing an IV to get ready for a CT chest angio c contrast, etc. cuz they don't wanna get sued. I get the EKG and cxr as a "just in case". Labs? eh... depends. How did the guy look?
    OOooh the suspense is killing me....

  3. We've had documented 98% coronary occlusions on 35-year old males, and I've coded a 37 y.o. in full v-fib with NO significant medical Hx.
    So at 45 isn't too young, he's well into the zone.
    DM + cardio HX = EKG and enzymes.
    Given the nausea, be suspicious. Neuropathy is a poor excuse to miss an early cardiac Dx.
    The workup was entirely reasonable, based on guidelines from my own CP clinicians.
    I'd rather spend the $ for tests to find no cardiac problems, than save them to miss a latent MI, pericarditis, etc.

    Which, besides the legal costs after the fact, really sucks for the patient, and doesn't cover one's hospital or staff with glory either.

    So we end up working up a lot of URIs, or patients with a low work note titer. That's what rule-out trees are for.

  4. Ok, so, personally, I think the guy had more "psychosocial" stuff going on. His brother died a week before (can't remember of what), and he was afraid he was going to die too. I'm not a doctor, but everything seemed to point to upper respiratory to me.

    The nausea wasn't mentioned until it was asked about during our triage process.

    Physical assessment was pretty normal. Lungs clear, no specific pain, etc. No travel, normal VS with a SLIGHTLY elevated BP (140s/90s, maybe). DM was mostly controlled. No insulin, only Metformin. Sugars in the low 100s. Pt presented nothing other than your typical cough/congestion/URI.

    The full cardiac workup seemed excessive to me. Once all labs and diagnostics came back normal, I was pretty darn sure we were gonna send this guy home.

    New Doc decided to admit. We only admit via hospitalist at our hospital, and only 2 of them regularly come down to do their own exam before writing orders and accepting the patient. The hospitalist on call that night was not one of them, so she accepted the patient.

    The guy had already been down in the ER about 5 hours, so I asked about drawing repeat cardiac enzymes, and, if normal, sending him home. New Doc said, "no, we'll just admit him."

    The patient didn't mind, though. He was pretty nervous after his brother's death and was fine with being in for observation.

    Like I said, it all seemed excessive to me, but what the hell do I know?

  5. The full cardiac package doesn't strike me as excessive, even though we know 95% of them are negative. It's the one you don't do that kills the patient and gets everyone sued.
    The admit, OTOH, I'll concede was rather stupid and pointless.
    I'm guessing he had a positive Blue Cross Titer.
    (What?? A hospital trying to recover costs on the back of the employed?!? Bastards!)

    Our SOP would have been to do between 2-4 repeat trops, and either stress test in the morning after #4 (if the doc had serious concerns about a cardiac issue, which an implanted pacemaker is a pretty good predictor for), or, based on your description, D/C after the second negative set, and refer to PMD/cardiologist along with an Rx for Tylenol, chicken soup, and a teddy bear.

    A phone consult with his cardiologist on call would probably have been the tipping point either way, and the only way we'd admit would be if he *failed* a treadmill stress test in the AM, in which case he'd clearly have bigger fish to fry than just a little (or a lot of)psychosocial stress.

  6. Aren't you just a nurse?

  7. 45yo under stress from a recent death with some atypical MI symptoms? Admission is stupid after negative Trops, but the enzymes were worth checking out. Of course, I'm a cardiothoracic ICU RN....so we're prone to assuming the worst (having seen the worst). A pacer at 45? Probably CM of some variety, or VT issues if it's an ICD. Really depends on what "cardiac issues" means.