The Robert B. Miller College
BSRN-340-Pharmacology for Nursing Care
Instructor: Mr. James Middleton
February 26th, 2009
Case Study #2 – Vague complaints of pain in the Emergency Department Many people that come to the emergency department who complain of pain are usually vague about their symptoms. Other people over-react and could win an Oscar nomination for their pain presentation. People who come in with vague complaints of pain are often puzzled and sometimes very non-specific to the area that hurts them. I came across an article in the Journal of Emergency Nursing about a man who complained of vague back pain. In this article, a 49-year-old man presented to the emergency department complaining of non-specific, aching, low back pain that he rated a 7 on a 0-10 scale. His discomfort began that morning after he bent over to pick something off the floor. The pain did not radiate and intensified with prolonged periods of standing still. The patient denied any weakness or paresthesia of the lower extremities and had no urinary complaints. “His respirations were slightly labored, but the man denied chest pain or shortness of breath. However, he was hypertensive (blood pressure 158/100), and febrile (temperature, 38.5C / 101.3F). The triage nurse assigned him a non-urgent acuity rating and placed him in the waiting room, where he waited for approximately 5 minutes.” (Jeremy Johnson, 2008). The man’s medical history was pretty normal but he had a long history of hypertension and recent history of an upper respiratory infection. According to (Jeremy Johnson, 2008), “Physical examination was positive for mild tendereness to palpation over the mid thoracic area of his back. Auscultation of heart and lung fields revealed no murmurs, gallops, or rubs and no wheezing or respiratory distress.” The patient’s back pain was diagnosed as a muscle strain, and he was treated with a combination of medication, valium, lortab, toradol and was given some acetaminophen for his fever. A peripheral intravenous access was established, and a liter of normal saline was infused. The patient’s ED stay was uneventful; however, as the anticipated discharge time grew closer, the nurse noted the man remained tachycardic and was now hypotensive “98/68 – 119 bmp. Although this patient denied any new complaints, his failure to respond to therapy warranted futher evaluation. A 12 lead EKG showed no ST abnormalties, but chest radiograph revealed a grossly wide mediastinum. This finding prompted a contrast computed tomography scan demonstrated the presence of a complex aneurysmal aortic dissection that extended all the way down to his right iliac artery.” “The mediastinum is the "middle" section of the chest cavity. The chest cavity contains the left and right lungs, which lie on either side of the heart. The heart is contained in the portion of the chest known as the mediastinum. The mediastinum is bordered by the thoracic inlet (where the organs of the neck enter the chest) on top, by the diaphragm on the bottom, the sternum (breastbone) in front, and the vertebral column (backbone) to the rear. The mediastinum is artificially divided into the anterior, middle and posterior sections. The mediastinum contains all of the chest organs except the lungs. Organs located in the mediastinum include the heart, the aorta, the thymus gland, the chest portion of the trachea, the esophagus, lymph nodes and important nerves.” (Medicine). Once the diagnosis of aortic dissection is made, a patient’s potential for rapid deterioration and death must be considered constantly. “Signs and symptoms of aortic rupture include acute mental status decline, hoarseness due to stretching and compression of the recurrent laryngeal nerve, differences between...