Presented By Me Nursing 630

The Case of A Little Too Much

HISTORY AND REVIEW OF SYSTEMS PERTINENT TO THE CASE

Chief Complaint
CC is a 24 year old Caucasian female who presents with a Chief Complaint of headaches and chest discomfort.

HPI
The headaches started this AM when patient woke up Describes the head as heavy; not unilateral; no photophobia; Not the worse head of her life. She states that the headache is mainly at the back of her head. States her heart was fluttering this morning and lasted for about 2hrs.; but is now improving; Denies chest pain; no radiation of pain; denies shortness of breathe. She states that she has never experienced her heart fluttering before She denies the use of any medications. She states that she had a couple of drinks yesterday during the day while out with friends; she couldnt quantify the intake. Had several episodes of nausea and vomiting last night.

Past Medical History

Adult illness: Asthma Childhood illnesses: Recurrent ear infections, Psychiatric illnesses: Anxiety Surgical History: Tonsillectomy

Current Health Status

Allergies: No Known Drug or Food allergies Immunizations: MMR, Varicella, TD all less than 10 years; Yearly Flu shot. Screening Test: test 3 years ago Safety Measures: Uses seatbelt, helmet on bicycles, no firearms in the Last Physical Examination over a year ago, last Pap

home.
Exercise: Sleep Patterns: Does not exercise Sleeps well at night

Diet:
Habits: street drugs.

Regular diets
Smokes ocassionally, occasional alcohol use, no use of

Family History

Father: CVA Mother: HTN No Siblings

Social History

Housing: Lives with her boyfriend. Support Systems: Boyfriend Recently started a new job. Sexual History: Sexually Active with her boyfriend only.

Review of System (Pertinent)

General: No weight loss or gain; Generalized fatigue; No Fever. Skin and Hair: No Rash HEENT No loss of vision, occasional headaches; Cardiac: no dizziness Respiratory/CV: No Shortness of Breath, or hemoptysis. GI: No diarrhea, no hematemesis No jaundice

Hematology: No abnormal bleeding OB/GYN: Normal Pap smear 1 yr. ago; . Neurological: No change in mental status Endocrine: Fatigue . Musculoskeletal: Occasional joint pain. Mental Health: Stressed, no depression.

PERTINENT PHYSICAL EXAMINATION

What Systems Should we focus on?

Physical Examination
Thin white female Alert and Oriented NAD VS BP: 145/80 RR:18 O2 Sat: 100% on RA T: 98.2 HR: 110 Skin Nails without clubbing or cyanosis. HEENT: Dry mucosa Throat: No goiter, thyromegaly; barely palpable, no lymphadenopathy. Lungs: CTA, No Wheezes GI/GU: Soft, slightly tender. LMP: 1 week ago Cardiac: + Orthostatic BP Normal S1, S2; No murmurs; No rubs; No gallops. No JVD M. System: FROM No deformities Peripheral Vascular System No peripheral edema of LEs Neuro: Alert and oriented, CN I VII intact; no confusion noted

What is Missing from the Physical Examination

Psych
CAGE Question Cut back Annoyed Guilty Eye Opener

Physical Examination
Panic Disorder Questionnaire

Have you experienced brief periods, for seconds or minutes, of an overwhelming panic or terror that was accompanied by racing heartbeats, shortness of breath, or dizziness?

Abbot A.V (2005). Diagnostic Approach to Palpitations. Retrieved from http://www.aafp.org/afp/2005/0215/p743.pdf

Lab
Normal Chest X-ray EKG: ST Glucose 95 U/A dip Specific Gravity >1.025 RBC +3

Chest X-ray

ECG

What are the Possible Differential Diagnosis?

 Palpitations are secondary to underlying problems such as anxiety, medications, cardiac or pulmonary origin.

Cash, J., & Glass, C. (2011). Family practice guidelines (2nd ed.). New York: Springer Publishing Company

Differential Diagnosis

o Dehydration o Holiday Heart Syndrome (Paroxysmal Supraventricular

Tachycardia or Atrial Fibrillation or Atrial Flutter)

o Hyperthyroidism o Anxiety/Panic Disorder o MI

Dirks J. (2007).Supporting Your Patient through Holiday Heart. Critical Care 37(2). Budzikowski A.S (2012).Holiday Heart Syndrome. Medscape

Pathophysiology

The term Holiday Heart Syndrome was coined in 1978. Benign in nature It is an acute cardiac rhythm and/or conduction disturbance, most commonly supraventricular tachyarrhythmia, associated with heavy ethanol consumption in a person without other clinical evidence of heart disease. Modest Alcohol Intake can act as a trigger in some people.

Pathophysiology

Alcohol Mechanism Theorized

Increased secretion of epinephrine and norepinephrine. Increased sympathetic output Decreased Sodium current (leading to altered pH level: with low dose=acidosis; high dose = alkalosis) acetaldehyde, the primary metabolite of alcohol, or fatty acid ethyl esters, a cardiac alcohol metabolite

Arrhythmia resolves within 24hrs of , even without any treatment

Dirks J. (2007).Supporting Your Patient through Holiday Heart. Critical Care 37(2). Budzikowski A.S (2012).Holiday Heart Syndrome. Medscape

A Standard Drink Contains

12 fluid ounces of beer (about 5% alcohol) 8 to 9 fluid ounces of malt liquor (about 7% alcohol) 5 fluid ounces of table wine (about 12% alcohol) 1.5 fluid ounces of hard liquor (about 40% alcohol)

How Would You Manage Ms. CCs Case?

Therapeutic Plan

Diagnostics

Therapeutics

Patient Education and Follow Up

Evaluating Palpitations

http://www.aafp.org/afp/2005/0215/p743.html

Therapeutic Plan
1. Holiday Heart Syndrome:
Diagnostic:
o Additional Lab: Cardiac Enzymes, CBC, Chem Panel, TSH

Therapeutics: none

(beta blockers or calcium channel blockers) if dyspnea or sustained palpitations or chest pain. Holter Monitor: If symptom persists.

Patient Education:
Alcohol abstinence, Eliminate other triggers like caffeine, ephedrine, stimulants like cocaine. Teach Valsalva maneuver or carotid massage or hands in cold water. Call 911 if symptoms recur and persist. Avoid exertion for the next 48 hours

Follow Up: In 2-3 days for lab work. Cardiologist Referral (Especially with syncope or near syncope)
Budzikowski A.S (2012).Holiday Heart Syndrome. Medscape Cash, J., & Glass, C. (2011). Family practice guidelines (2nd ed.). New York: Springer Publishing Company

Therapeutic Plan

2. Dehydration
Diagnostic: + Orthostatic BP Therapeutics: 1 liter NS via IV infusion. Patient Education:
Maintain hydration.

Headache

Tension headache Diagnostic: None Therapeutic: Tylenol 650mg Prn headaches. Patient Education Stay hydrated

Role of the Nurse Practitioner

Partnership with the pt. Support care for pt. Referral and consultation(Cardiologist) Follow up Patient and Family education

Follow Up & Case Summary

Reports no use of alcohol since last visit No recurrent palpitations EKG: Sinus Rhythm. LAB: WNL No Myopathy found on echo

Reference
ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular ArrhythmiasExecutive Summary. Retrieved from

Abbott A.V (2005). Diagnostic Approach to Palpitations. American Family Physician. 71(5). Budzikowski A.S (2012).Holiday Heart Syndrome. Medscape. Cash, J., & Glass, C. (2011). Family practice guidelines (2nd ed.). New York: Springer Publishing Company Dirks J. (2007).Supporting Your Patient through Holiday Heart. Critical Care 37(2). Pittman H. (2004). Recognizing Holiday Heart Syndrome. Nursing 34(12).

http://circ.ahajournals.org/content/108/15/1871