Vague complaints of pain in the Emergency Department Susan M. Hewitt RN, CEN The Robert B. Miller College BSRN-340-Pharmacology for Nursing Care Instructor: Mr. James Middleton February 26th, 2009 Case Study #2 – Vague complaints of pain in the Emergency Department Many people that come to the emergency department who complain of pain are usually vague about their symptoms. Other people over-react and could win an Oscar nomination for their pain presentation.
People who come in with vague complaints of pain are often puzzled and sometimes very non-specific to the area that hurts them. I came across an article in the Journal of Emergency Nursing about a man who complained of vague back pain. In this article, a 49-year-old man presented to the emergency department complaining of non-specific, aching, low back pain that he rated a 7 on a 0-10 scale. His discomfort began that morning after he bent over to pick something off the floor.
The pain did not radiate and intensified with prolonged periods of standing still.
The patient denied any weakness or paresthesia of the lower extremities and had no urinary complaints. “His respirations were slightly labored, but the man denied chest pain or shortness of breath. However, he was hypertensive (blood pressure 158/100), and febrile (temperature, 38. 5C / 101. 3F). The triage nurse assigned him a non-urgent acuity rating and placed him in the waiting room, where he waited for approximately 5 minutes. ” (Jeremy Johnson, 2008). The man’s medical history was pretty normal but he had a long history of hypertension and recent history of an upper respiratory infection.
According to (Jeremy Johnson, 2008), “Physical examination was positive for mild tendereness to palpation over the mid thoracic area of his back. Auscultation of heart and lung fields revealed no murmurs, gallops, or rubs and no wheezing or respiratory distress. ” The patient’s back pain was diagnosed as a muscle strain, and he was treated with a combination of medication, valium, lortab, toradol and was given some acetaminophen for his fever. A peripheral intravenous access was established, and a liter of normal saline was infused.
The patient’s ED stay was uneventful; however, as the anticipated discharge time grew closer, the nurse noted the man remained tachycardic and was now hypotensive “98/68 – 119 bmp. Although this patient denied any new complaints, his failure to respond to therapy warranted futher Assessment. A 12 lead EKG showed no ST abnormalties, but chest radiograph revealed a grossly wide mediastinum. This finding prompted a contrast computed tomography scan demonstrated the presence of a complex aneurysmal aortic dissection that extended all the way down to his right iliac artery. “The mediastinum is the “middle” section of the chest cavity. The chest cavity contains the left and right lungs, which lie on either side of the heart. The heart is contained in the portion of the chest known as the mediastinum. The mediastinum is bordered by the thoracic inlet (where the organs of the neck enter the chest) on top, by the diaphragm on the bottom, the sternum (breastbone) in front, and the vertebral column (backbone) to the rear. The mediastinum is artificially divided into the anterior, middle and posterior sections. The mediastinum contains all of the chest organs except the lungs.
Organs located in the mediastinum include the heart, the aorta, the thymus gland, the chest portion of the trachea, the esophagus, lymph nodes and important nerves. ” (Medicine). Once the diagnosis of aortic dissection is made, a patient’s potential for rapid deterioration and death must be considered constantly. “Signs and symptoms of aortic rupture include acute mental status decline, hoarseness due to stretching and compression of the recurrent laryngeal nerve, differences between carotid pulse amplitiudes, and catastrophic hemodynamic collapse.
Fortunately, this patient remained awakee and alert throught his ED stay. His tachycardia and hypotension both improved with metoprolol (lopressor) and fluid administration. He was admitted to the hospital and later flown to an out-of-state facility for surgical repair of his dissection. ” (Jeremy Johnson, 2008). This article was very impressive, people who come to the emergency department often have vague complaints of pain. This is why the emergency department staff should be very knowledgeable in pain management.
If the nurse did not pick up on the patient’s vital sign deterioration, the patient could have went home and died. Aortic disease is more prevalent in men than in woman and primarily occurs between the ages of 60 and 70. “Most disordeers are a result of hypertension, trauma, pregnancy, or genetic conditions such as Marfan’s syndrome. ” (Jeremy Johnson, 2008). “What is Marfan’s Syndrome? ” “The Marfan syndrome is a connective tissue disorder. Connective tissue provides substance and support to tendons, ligaments, blood vessel walls, cartilage, heart valves and many other structures.
In the Marfan syndrome, the chemical makeup of the connective tissue isn’t normal. As a result, many of these structures aren’t as stiff as they should be. ” “The Marfan syndrome is inherited and affects many parts of the body. There’s no single conclusive test for diagnosing it, but people who have it often have many similar traits. Besides perhaps having heart problems, people with the Marfan syndrome are often tall and thin. They also may have slender, tapering fingers, long arms and legs, curvature of the spine and eye problems.
Sometimes the Marfan syndrome is so mild that few (if any) symptoms exist. In the most severe cases, which are rare, life-threatening problems may occur at any age. ” (Association, 2009). In conclusion, I think that this article was very informative and would make a good case study because many health care giver’s now days are in the bad habit of sterotyping people with pain as “drug seekers”. I also thought it was a good case study, because the nurse taking care of this patient was on top of her game. The patient did not present with typical aortic dissection signs and symptoms.
Usually a patient complains of a “tearing sensation” to their back, some chest pain and hypertension. This man was vague in his back pain complaint, if not for knowledge of the nurse taking care of this patient he/she saved his life. Also, they gave him analgesics in which we recently read about. The patient’s pain was taken care of by narcotic, benzodiazapines, and anti-inflammatory medication. Also, they kept him for the 30 minute time after drug administration, to make sure there is no adverse reaction. This was a good choice especially for this lucky man who ltimaltely ended up with a dissecting aortic aneurysm. This is what killed John Ritter and many other’s who probably ignored their pain or masked their pain with medication. So if you ever have a tearing sensation in your back with a history of hypertension or Marfan’s Syndrome, take yourself to the emergency department immediately. This case also reinforces the importance of ongoing assessment and further invervention when Patients do not respond as expected to treatement. Many serious disorders can present with vague symptoms, making continual reassessment and risk stratification essential.
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