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Emergency Severity Index Pt.2: Practice Cases – 20 Epigastric Area Pressure

November 4, 2019

[Music] Facilitator 1 (FA1): Why don’t we watch
another patient scenario? Nurse (N): Louise Wood?
Patient (P): Yes. N: Hi, come on in, Louise. Doing okay there? Why don’t you have a seat?
My name is Paula. I’m going to ask you a couple questions about what brought you in here today and get your blood pressure, okay? P: Okay. I feel really silly being here,
but the girls where I work insisted that I come over and get
checked out. N: So, what’s going on? P: I have this pain… it’s like a constant pressure. It’s not like my heartburn. This makes me sick to my stomach. N: How long has this been going on? P: About three hours. N: Okay. Have you taken anything for it? P: One of my co-workers gave me an antacid It didn’t do anything. I’m just so tired. N: Okay, I’m gonna get your blood pressure and ask you a couple more my questions.
How old are you? P: 57 N: Okay, and on a scale of 0 to 10, with
10 being the worst pain that you can imagine, how would you rate that pain right now? P: About seven. N: Okay, and… P: Nurse, this isn’t gonna take long, is it?
Because I’ve got to get back to work – I’ve got so much work to do. N: You know, I can’t tell you
exactly how long it’s going to take, but it is really important that you see the doctor today. P: Okay.
N: Okay. Do you have any medical
problems? P: I have a high cholesterol and I’ve had some heartburn lately. N: Okay, do you take any medicines
every day on a regular basis? P: Yes, it’s here in my purse. N: Okay, can I see? Great. Thanks. [Music] FA1: This 57 year old female presents to the
emergency department with epigastric area pressure. She has a history of high
cholesterol and seems to be stressed about work – all risk factors for cardiac
disease. We know from the research that women with heart disease do not present
with the classic signs of chest pain and shortness of breath.
Usually, their discomfort is more upper GI and many will complain of
being tired. This patient is currently stable and
does not require immediate life-saving interventions, but she is high risk for
cardiac disease. She meets the criteria for ESI Level 2. If her blood pressure
was low or her heart rate was high, low or irregular, and her skin was cool and
diaphoretic, she would then be an ESI Level 1. This patient is
currently ESI Level 2. FA1: Interesting woman. What do you think? Do you agree with that? Registered Nurse 1 (RN1): Yes, that
really makes sense. FA1: Women are different, aren’t they?
Group: Yes Registered Nurse 2 (RN2): One of the first things I noticed about her is that she is very short of breath
and that kind of alarmed me. So, the whole time that she was talking to you,
just – that was what I was thinking about. Okay, that she’s short of breath,
you know, I need to try to help. FA1: You needed to do something to intervene –
RN2: soon FA1: – even if she was
just being dramatic, you know, which, you know, obviously in an
emergency department, we have patients who present that way. Would that change
your priority rating at all? Would you still make her a 2? RN1: I would and I was
considering the question of whether she was hysterical and nervous or whether
she was actually short of breath. The other thing is that she did take an
antacid and it didn’t help at all, which leans me still further in the direction
of a possible cardiac condition FA1: That’s an excellent point. Now,
women with heart disease, they tend to deny their pain. We know that. There’s a lot of
things we’re learning in the last ten years about women and how they present
to the emergency department. You know, we need to make sure that they get seen.
Does anybody have any other questions about this particular patient? Anything they
want to say? RN1: No, she was – her vital signs were normal? FA1: They were. RN1: But still… FA1: Blood pressure, heart rate, everything. She just, as you said, was a little tachypneic. RN3: And I didn’t see her SPO2. What was that? FA1: Um, I believe it was
a hundred percent. It was normal. RN3: Because, again, I thought the
shortness of breath was quite evident. FA2: I wanted to give her an emesis
basin. FA1: Oh, that’s a good point. FA2: She had so much up epigastric distress, just watching the video, I was concerned.
And that bothered me a lot, too. Well, we really tend to blow off women and even
in some of the teaching that we do, we still find a lot of nurses that don’t
want to take females seriously with this kind of chief complaint. And it’s kind of
surprising, that still are people that want to minimize women with epigastric
distress. It’s not something that you want to do. RN1: We make it easy.
They’re so vague in their complaints – we’re so vague in how we speak about our
complaints. We tell too much. FA1: What would you have to look like to
make her a Level 1? RN3: Well, some instability in the vital signs. FA1: What if I said her heart rate was 180? RN1: Then she’d go up.
Group: Definitely. RN1: If her color looked worse, as well. If she
had diaphoresis as well as the epigastric distress and the shortness of
breath. RN3: Either hypotension or hypertension, either one. FA1: Good
interesting case I think we learned a lot in that one.

1 Comment

  • Reply Brian Numme June 6, 2019 at 9:48 pm

    What drugs was she taking?

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