Case Report
Content
Steps to Success: Developing a Case Study for Publication
Janie Heath PhD, APRN-BC Associate Dean, Academic Nursing Practice Medical College of Georgia
Michael Muscat
Managing Editor
American Journal of Critical Care
BBQ and Smoking: An Atypical Chest Pain Case Report
Step 1: Is this a Good Case?
A 38 yr old African American male experienced chest pain after attending an outdoor BBQ. The day before he was dropped from a tobacco cessation study (randomized to Quest Cigarettes) because of uncontrolled HTN. He has a hx of using marijuana “socially” and currently is without insurance. After 4 hours of discomfort he goes to a local E.R. where a $3500 diagnostic workup and admission to the 24 hr Observation Unit resulted in a dsc dx of “Atypical Chest Pain of Unknown Etiology”.
Are There Clues for Uniqueness?
• • • • • • •
38 yr old African American male Attended an outdoor BBQ Dropped from a tobacco cessation study (randomized to Quest Cigarettes) because of uncontrolled HTN Hx of using marijuana “socially” Currently without insurance Dsc dx of “Atypical Chest Pain of Unknown Etiology”
What Validates the Worthiness to Report the Case (Pg 13)?
• Represents a newly described
• • •
syndrome or disease An unexpected association of two diseases or conditions that may have a causal relation The “outlier” case that represents a variation for the expected A case with a surprising evolution that suggests a therapeutic or adverse drug effect
Step 2: Is It Important to Report This Case?
• The USPHS (2000) Evidence-Based
Tobacco Cessation Guideline recommends to use the 5 As (ask, advise, assess, assist, arrange) framework
– Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.
• If more evaluation was done with
the 1st A (ask), a $3500 diagnostic work up and 24 hr Observation Unit Admission might have been prevented
Step 2: Is It Important to Report This Case?
• Quest cigarettes have lower
nicotine levels and are promoted as a “safer” way to quit smoking • This case provides evidence that a combination of BBQ exposure and the use of Quest cigarettes and marijuana resulted in dangerous CO levels
Step 3: Introduction Essentials (Pg 21)
• Tobacco use is the #1 preventable
cause of death – 437,902 deaths r/t tobacco use per yr – 32% (137,979) from CV dz > 4800 toxins, to include carbon monoxide (CO), are released when smoking ONE cigarette (direct & indirect)
•
Centers for Disease Control and Prevention. (2005). MMWR 54:625–628
Step 3: Introduction Essentials (Pg 21)
• Cigarette smoking potentiates platelet
• •
aggregation, thrombosis, catecholamine release, and activation of inflammatory responses Lower nicotine cigarettes (Quest) can produce compensatory smoking and increased CO exposure CO exposure can be found in grilled foods and any type of smoke (such as BBQ and marijuana)
National Cancer Institute (NCI). (2001). Risks Associated with Low Machine-Measured Yields of Tar and Nicotine (NIH Publication No. 02-5074). Smoking and Tobacco Control Monograph No. 13. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute.
Step 3: Introduction Essentials (Pg 21)
• Many heavy smokers (> 1 pk/d) can have a CO
• •
level of 60 (ppm) or 9% COHb without symptoms Levels of 90 ppm / 15% COHb result in mild symptoms (headache, nausea, fatigue) Levels of 150 ppm / 25% COHb can be treated effectively with fresh air or oxygen Levels of 180 ppm or 30% COHb can result in long term health effects Levels of 270 ppm or 45% COHb can result in unconsciousness Levels > 300 ppm or 50% COHb can result in death
•
•
• • The COHb in this case study (22%) was
overlooked
–
Townsend C. L and Maynard R. L (2002). Effects on health of prolonged exposure to low concentrations of carbon monoxide. Occup Environ Med 59 , 708-11.
Step 3: Introduction Essentials (Pg 21)
• Differential Diagnosis
– – – – – – Myocardial Infarction Thoracic Aneurysm Angina Pectoris Pulmonary Emboli Pneumonia PUD
Step 4: The History Essentials
• Ray, a 38 yr old b/m presented to the ER
after a 4 hr period of substernal chest pain. States attended a BBQ with friends and felt nauseated after smoking his regular cigarettes. Admits probably “over did” it since he was in a study to quit smoking and could not smoke “his own” cigarettes. Reports nothing different happening except dropped from “quit smoking” study because B/P was too high.
Step 4: The History Essentials
• ROS
No fever, trauma, or injury +chest discomfort, substernal area w/o radiation 5/10, + nausea, denies diaphoresis, anorexia, vomiting, diarrhea, or constipation, + 3 day fatique No Cough / SOB / DOE No headache/dizziness
PMH/PSH
FMH
No Meds; NKA
+ tobacco use (mother, father, and 2 sisters) + HTN and CAD (mother and father) + ETOH use 1-2 beers qod; no OTC or Herbs/Supplements + Marijuana use x1-2 x/ mth (social gatherings) + Tobacco use x 15 yrs (1.5 pk/d) Lives alone; single, paralegal for Dept of Justice, applying for law school, heterosexual with 1 partner
Social Hx
Step 4: The Physical Exam Essentials
• WD, WN male appears anxious but NAD • VS: 97.5, 110, 22, 145/90, 98% RA, • • • •
5/10 for pain scale CV:S1 S2, RRR and tachy, no murmur or rub, PMI slightly displaced, no thrills, no JVD, pulses intact RESP:CTA bilaterally ABD: ND, no visible pulsations/hernias, NABS, no bruits, no tenderness, no mass Remaining exam WNL
Step 4: Relevant Labs
• CBC- elevated
HCT • CHEM- wnl • UA- wnl • CPK-MB- wnl • Troponin- wnl
• CXR- wnl • EKG- Sinus
Tach
Step 4:Treatment Plan
• O2, IV, Monitor • Chew ASA stat • Nitro SL stat and 1 q • • • • •
10 min x3 prn chest pain MS 2mg IV q 4 hrs PRN pain unrelieved by initial Nitro SL Admit 24 hr Observation Unit Clear liquid diet Repeat EKG q 4 hrs Repeat CK-MB and Troponin at 7am
Step 5: Literature Discussion (Pg 30)
• The MISSED Differential Diagnosis
– Carbon Monoxide Toxicity
• African American = Slower metabolism of •
• •
•
cotinine Low nicotine cigarettes = higher consumption, increased puff volume, and increased CO Smoking ONE marijuana = 4 cigarettes Smoking ONE marijuana = 3 x the amount CO in one cigarette BBQ smoke exposure =
Step 5: Literature Discussion (Pg 30)
• Differential Diagnosis
– – – – – – – Angina Pectoris Myocardial Infarction Thoracic Aneurysm Pulmonary Emboli Pneumonia PUD Carbon Monoxide Toxicity
Janie Heath PhD, APRN-BC Associate Dean, Academic Nursing Practice Medical College of Georgia
Michael Muscat
Managing Editor
American Journal of Critical Care
BBQ and Smoking: An Atypical Chest Pain Case Report
Step 1: Is this a Good Case?
A 38 yr old African American male experienced chest pain after attending an outdoor BBQ. The day before he was dropped from a tobacco cessation study (randomized to Quest Cigarettes) because of uncontrolled HTN. He has a hx of using marijuana “socially” and currently is without insurance. After 4 hours of discomfort he goes to a local E.R. where a $3500 diagnostic workup and admission to the 24 hr Observation Unit resulted in a dsc dx of “Atypical Chest Pain of Unknown Etiology”.
Are There Clues for Uniqueness?
• • • • • • •
38 yr old African American male Attended an outdoor BBQ Dropped from a tobacco cessation study (randomized to Quest Cigarettes) because of uncontrolled HTN Hx of using marijuana “socially” Currently without insurance Dsc dx of “Atypical Chest Pain of Unknown Etiology”
What Validates the Worthiness to Report the Case (Pg 13)?
• Represents a newly described
• • •
syndrome or disease An unexpected association of two diseases or conditions that may have a causal relation The “outlier” case that represents a variation for the expected A case with a surprising evolution that suggests a therapeutic or adverse drug effect
Step 2: Is It Important to Report This Case?
• The USPHS (2000) Evidence-Based
Tobacco Cessation Guideline recommends to use the 5 As (ask, advise, assess, assist, arrange) framework
– Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.
• If more evaluation was done with
the 1st A (ask), a $3500 diagnostic work up and 24 hr Observation Unit Admission might have been prevented
Step 2: Is It Important to Report This Case?
• Quest cigarettes have lower
nicotine levels and are promoted as a “safer” way to quit smoking • This case provides evidence that a combination of BBQ exposure and the use of Quest cigarettes and marijuana resulted in dangerous CO levels
Step 3: Introduction Essentials (Pg 21)
• Tobacco use is the #1 preventable
cause of death – 437,902 deaths r/t tobacco use per yr – 32% (137,979) from CV dz > 4800 toxins, to include carbon monoxide (CO), are released when smoking ONE cigarette (direct & indirect)
•
Centers for Disease Control and Prevention. (2005). MMWR 54:625–628
Step 3: Introduction Essentials (Pg 21)
• Cigarette smoking potentiates platelet
• •
aggregation, thrombosis, catecholamine release, and activation of inflammatory responses Lower nicotine cigarettes (Quest) can produce compensatory smoking and increased CO exposure CO exposure can be found in grilled foods and any type of smoke (such as BBQ and marijuana)
National Cancer Institute (NCI). (2001). Risks Associated with Low Machine-Measured Yields of Tar and Nicotine (NIH Publication No. 02-5074). Smoking and Tobacco Control Monograph No. 13. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute.
Step 3: Introduction Essentials (Pg 21)
• Many heavy smokers (> 1 pk/d) can have a CO
• •
level of 60 (ppm) or 9% COHb without symptoms Levels of 90 ppm / 15% COHb result in mild symptoms (headache, nausea, fatigue) Levels of 150 ppm / 25% COHb can be treated effectively with fresh air or oxygen Levels of 180 ppm or 30% COHb can result in long term health effects Levels of 270 ppm or 45% COHb can result in unconsciousness Levels > 300 ppm or 50% COHb can result in death
•
•
• • The COHb in this case study (22%) was
overlooked
–
Townsend C. L and Maynard R. L (2002). Effects on health of prolonged exposure to low concentrations of carbon monoxide. Occup Environ Med 59 , 708-11.
Step 3: Introduction Essentials (Pg 21)
• Differential Diagnosis
– – – – – – Myocardial Infarction Thoracic Aneurysm Angina Pectoris Pulmonary Emboli Pneumonia PUD
Step 4: The History Essentials
• Ray, a 38 yr old b/m presented to the ER
after a 4 hr period of substernal chest pain. States attended a BBQ with friends and felt nauseated after smoking his regular cigarettes. Admits probably “over did” it since he was in a study to quit smoking and could not smoke “his own” cigarettes. Reports nothing different happening except dropped from “quit smoking” study because B/P was too high.
Step 4: The History Essentials
• ROS
No fever, trauma, or injury +chest discomfort, substernal area w/o radiation 5/10, + nausea, denies diaphoresis, anorexia, vomiting, diarrhea, or constipation, + 3 day fatique No Cough / SOB / DOE No headache/dizziness
PMH/PSH
FMH
No Meds; NKA
+ tobacco use (mother, father, and 2 sisters) + HTN and CAD (mother and father) + ETOH use 1-2 beers qod; no OTC or Herbs/Supplements + Marijuana use x1-2 x/ mth (social gatherings) + Tobacco use x 15 yrs (1.5 pk/d) Lives alone; single, paralegal for Dept of Justice, applying for law school, heterosexual with 1 partner
Social Hx
Step 4: The Physical Exam Essentials
• WD, WN male appears anxious but NAD • VS: 97.5, 110, 22, 145/90, 98% RA, • • • •
5/10 for pain scale CV:S1 S2, RRR and tachy, no murmur or rub, PMI slightly displaced, no thrills, no JVD, pulses intact RESP:CTA bilaterally ABD: ND, no visible pulsations/hernias, NABS, no bruits, no tenderness, no mass Remaining exam WNL
Step 4: Relevant Labs
• CBC- elevated
HCT • CHEM- wnl • UA- wnl • CPK-MB- wnl • Troponin- wnl
• CXR- wnl • EKG- Sinus
Tach
Step 4:Treatment Plan
• O2, IV, Monitor • Chew ASA stat • Nitro SL stat and 1 q • • • • •
10 min x3 prn chest pain MS 2mg IV q 4 hrs PRN pain unrelieved by initial Nitro SL Admit 24 hr Observation Unit Clear liquid diet Repeat EKG q 4 hrs Repeat CK-MB and Troponin at 7am
Step 5: Literature Discussion (Pg 30)
• The MISSED Differential Diagnosis
– Carbon Monoxide Toxicity
• African American = Slower metabolism of •
• •
•
cotinine Low nicotine cigarettes = higher consumption, increased puff volume, and increased CO Smoking ONE marijuana = 4 cigarettes Smoking ONE marijuana = 3 x the amount CO in one cigarette BBQ smoke exposure =
Step 5: Literature Discussion (Pg 30)
• Differential Diagnosis
– – – – – – – Angina Pectoris Myocardial Infarction Thoracic Aneurysm Pulmonary Emboli Pneumonia PUD Carbon Monoxide Toxicity
