I do not know what to do

A recent case highlights a common conundrum that happens to the best of us. You are presented with a situation where you simply do not know what to do.

A 23 yr old patient presented with tachyarrythmias following a night of heavy drug and alcohol use. Her presenting vitals are normal. Her toxidrome is clearing and her level of consciousness has improved. She however has chest pain and her heart rate remains 140 despite fluids, ativan and cooling. She had used some ecstasy and marijuana and a lot of alcohol. At one point she had an ECG that seemed to look like Atrial Fibrillation but the subsequent ones show a sinus tachy. You get a D-Dimer and a set of enzymes that are negative. Your chest X-ray is negative. You do a POCUS which is negative. Her parents then come to the department. You learn that her father is a family doctor in town and her mother is a radiologist in a rural hospital you have worked at. They have numerous questions about the chest pain that the young lady is experiencing and make some phone calls to their friends who include some cardiologists and internists that you know of. They all throw around some diagnoses that include PE, myocarditis and boor haves, none of which look like her current problem. She is rather chatty with her parents but very withdrawn with you and almost seems to dislike you. Her parents are equally frustrated with your lack of answers. They do not feel like they can take her home. You are past your shift being over and your very nice colleague hears your long winded talk with the parents and says “don’t handover me that”. You give cardiology a quick call and they say “please do not refer us these types of cases. She has a sinus tachy with a chest pain NYD”. You are now exasperated. What do you do?

2 thoughts on “I do not know what to do

  1. I’m not clear medically what is going on here, is she in withdrawal?Did she take something else? does she have another metabolic derangement going on or a structural disease?

    I would ask medicine to see her (or admit her if you were in the community), keep her on a monitor, repeat BW, EKG, keep up with regular benzos (if you are suspecting tox/withdrawal).

    In my opinion, she would not be going home. I would explain to the parents, that you are unsure what is going on and want to keep her in hospital.

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  2. I agree with Alexis – still uncertain about what’s happening with this patient. She needs some more observation and repeat work-up.

    I would readdress the issue of confidentiality with the patient (ie that her medical condition/work-up would not be discussed with her parents, even though they are physicians in the community). Maybe she will feel more inclined to disclose her history with the medical team which could help with her management.

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