Mrs. W is a 59 year old woman who is severely anemic.
Back Story: When she was 45 years old and beginning menopause, an episode of heavy bleeding caused Mrs. W's doctor to recommend an endometrial biopsy. The procedure was profoundly painful. Mrs. W was not given any warning or pre-procedure education. During the biopsy, Mrs. W. (a dignified person under normal circumstances) was screaming in pain and could be heard in the waiting room. As soon as the biopsy was over and her feet were removed from the stirrups, she curled into a fetal position holding her abdomen, weeping, completely out of control. The physician and her assistants left Mrs. W. in the room, having told her she could get dressed and leave and need not stop at the front desk for a return appointment. Mrs. W. got dressed, left the office, walked across the parking lot, and drove herself home. A week later she was told "there was nothing wrong" with the biopsy. Since that time Mrs. W. has had similar episodes of bleeding. She knows that this can be a sign of endometrial cancer and has asked her doctor several times if she could have the procedure done with IV analgesia or light sedation. Each time she was told her insurance wouldn't pay for the pain control and that in any event "it's just not done". Since that time she has had episodes of dysfunctional uterine bleeding but Mrs. W. cannot bring herself to seek medical attention for fear she will have to suffer the agony and indignity she remembers from years past.
Current condition: At 1845 this evening, Mrs. W. was brought to the emergency room by paramedics, accompanied by her husband. He says they had just finished dinner at the kitchen table. His wife stood up to clear the table, lost consciousness, hitting her head on a kitchen counter as she fell. Mr. W. says that after her loss of consciousness his wife had a few "convulsion-like movements" before she woke up. There is a dressing on her head that is quite saturated.
Vital signs: T: 97.4, P: 135, R: 28, BP: 102/55, %sat: 100 on 2L/min oxygen.
Assessment: The nurse notes that Mrs. W. is a moderately tall woman with a thin body habitus. Her skin looks quite pale. The nurse's first priority is to perform a quick neuro-check on Mrs. W. She is awake and looks fearful (gripping her husband's hand and scanning the equipment in the ER bay.) She is oriented to time, place, person, and situation. She states she remembers feeling dizzy at the table but not her fall. Her pupils are equal and equally reactive to light (PEERL). She moves all four extremities equally, has no drift, equal strength in her left and right grips and dorsiplantar flexion. Admission labs are drawn and Mrs. W is quickly taken to the CT scan (head CT without contrast) showing that she has not had an intracranial bleed.
Labs:
Chemistries: Na+ 141, K+ 4.3, Cl- 118, HCO3- 24, BUN 15, Creatinine 0.9, Glucose 120.
Hematology: Hgb 5.9, Hct 19, WBC 8500, Platelets 180,000
Coagulation studies: Normal
Mrs. W. is asked to undress and don a gown and anti-slip socks. She asks to go to the bathroom first and requests a pad. The nurse brings Mrs. W. a bedside commode and a menstrual pad to replace the soaked one she is wearing. She is quite breathless as she returns to the gurney. The nurse notes straw colored urine containing a few shreds of blood. The nurse completes a physical assessment which, (apart from the head wound and vital signs) is essentially negative. The accumulation of evidence suggests to the nurse that Mrs. W. has blood loss anemia. When he checks her mucous membranes and conjunctiva, he finds them to be quite pale.
Diagnostics:
CXR: was read as normal.
12 lead EKG: shows sinus tachycardia with ST-elevation in the anterior leads (V3, V4) and reciprocal changes in leads II, III, and aVF.
Mrs. W. denies any chest pain. She affirms that she has been tired and breathless for "quite a while". A Code Stemi is called and the decision made to transfuse Mrs. W. immediately. She is typed and crossed for 4 units of packed cells. The first is begun within the next 20 minutes. She is then transferred to the Cardiac Care Unit and the remaining blood is administered over the next 10 hours.
Vital signs: T: 97.4, P: 135, R: 28, BP: 102/55, %sat: 100 on 2L/min oxygen.
Assessment: The nurse notes that Mrs. W. is a moderately tall woman with a thin body habitus. Her skin looks quite pale. The nurse's first priority is to perform a quick neuro-check on Mrs. W. She is awake and looks fearful (gripping her husband's hand and scanning the equipment in the ER bay.) She is oriented to time, place, person, and situation. She states she remembers feeling dizzy at the table but not her fall. Her pupils are equal and equally reactive to light (PEERL). She moves all four extremities equally, has no drift, equal strength in her left and right grips and dorsiplantar flexion. Admission labs are drawn and Mrs. W is quickly taken to the CT scan (head CT without contrast) showing that she has not had an intracranial bleed.
Labs:
Chemistries: Na+ 141, K+ 4.3, Cl- 118, HCO3- 24, BUN 15, Creatinine 0.9, Glucose 120.
Hematology: Hgb 5.9, Hct 19, WBC 8500, Platelets 180,000
Coagulation studies: Normal
Mrs. W. is asked to undress and don a gown and anti-slip socks. She asks to go to the bathroom first and requests a pad. The nurse brings Mrs. W. a bedside commode and a menstrual pad to replace the soaked one she is wearing. She is quite breathless as she returns to the gurney. The nurse notes straw colored urine containing a few shreds of blood. The nurse completes a physical assessment which, (apart from the head wound and vital signs) is essentially negative. The accumulation of evidence suggests to the nurse that Mrs. W. has blood loss anemia. When he checks her mucous membranes and conjunctiva, he finds them to be quite pale.
Diagnostics:
CXR: was read as normal.
12 lead EKG: shows sinus tachycardia with ST-elevation in the anterior leads (V3, V4) and reciprocal changes in leads II, III, and aVF.
Mrs. W. denies any chest pain. She affirms that she has been tired and breathless for "quite a while". A Code Stemi is called and the decision made to transfuse Mrs. W. immediately. She is typed and crossed for 4 units of packed cells. The first is begun within the next 20 minutes. She is then transferred to the Cardiac Care Unit and the remaining blood is administered over the next 10 hours.