Have you ever noticed that patients present with similar symptoms on a given day? What’s up with that? Why does it happen? It’s a mystery to me, but it happens regularly.
Take, for instance, last week in the urgent care oncology unit. We were asked to see a patient, Mr. A, who had first presented to his regular clinic with hypotension. There was no fever, but his physician was concerned there may be sepsis and explained the lack of fever as being caused by immune suppression related to cyclosporine and neutropenia.
When he arrived he indeed had hypotension, and his normal saline had already been started through his central line, infusing as fast as possible with an infusion pump set at 999 milliliters per hour. Our initial assessment included another set of vital signs (BP 76/50) and a cursory assessment. His lips were obviously very sore as a result of an extensive case of the herpes simplex virus (HSV), and, as a result, he was probably somewhat dehydrated.
During the assessment he started to complain of chest pressure (my least favourite symptom). I continued with the usual OLDCART assessment (onset, location, duration, characteristics, aggravating factors, relieving factors, and timing) and asked my nursing colleagues to do a stat troponin, call the doctor, and do a 12-lead ECG.
During the assessment Mr. A indicated that he had had this symptom once before when given IV fluids quickly. So I slowed down the IV and asked a few more questions while waiting for the physician to arrive. I also asked myself several questions: Could it be the HSV affecting the oesophagus? Could it be graft versus host disease of the GI tract? It turns out there was a cardiac history -- cardiomyopathy related to chemotherapy -- but it hadn’t caused any symptoms other than mild SOB on ambulation from time to time and apparently chest pressure with rapid IV infusion.
In a way it made sense. With his cardiomyopathy, increased fluids through rapid infusion was probably causing further dilation of the ventricles and causing the chest pressure. His ECG showed no acute changes, and the troponin was negative, but we needed to admit him in order to rehydrate over several hours rather than giving a rapid bolus. We certainly didn’t want to precipitate that pressure again. He agreed to the plan and I started my note.
In came the physician to investigate further, and behind him the nurse asking me to assess the women in the room next door. She was complaining of chest pain! Another complete assessment including a 12-lead ECG and additional blood work led me to believe this was related to costochondritis, probably as a result of excessive gardening the day before. Increased pain on inspiration and sensitivity to the exact area of her chest pain when I palpated the area convinced me of the cause.
I had just sat down to complete my admission notes for the case of Mr. A when the nurse came to my office: We have another patient coming from clinic, she told me.
"Better get the ECG machine set up," I said. "I bet he has chest pain."
"How did you know?" she asked. "Did they call you, too?"
"No, just a hunch."
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