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Getting to the Heart of Back and Shoulder Pain Kathleen Bradbury-Golas, DNP, APN, NP-C, ACNS-BC Theresa M

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Getting to the Heart of Back and Shoulder Pain Kathleen Bradbury-Golas, DNP, APN, NP-C, ACNS-BC Theresa M LWW/AENJ TME200069 April 26, 2010 11:12 Char Count= 0 Advanced Emergency Nursing Journal Vol. 32, No. 2, pp. 127–134 Copyright c 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Cases OF NOTE Column Editor: Theresa M. Campo, DNP, RN, APN, NP-C Getting to the Heart of Back and Shoulder Pain Kathleen Bradbury-Golas, DNP, APN, NP-C, ACNS-BC Theresa M. Campo, DNP, RN, APN, NP-C Anthony Chiccarine, DO, FACEP Abstract A healthy male presents to the emergency department with common musculoskeletal complaints that have shown no improvement after 10 days of conservative management. The emergency department provider notes a tachycardia and the patient confirms new onset shortness of breath for 1 day. After a comprehensive workup, the patient is admitted to the hospital. The purpose of this case presentation is to provide advanced practice nurses with information on the manifestations of what is initially felt to be musculoskeletal complaints. This article also emphasizes the need for an astute review of this patient’s “triage” vital signs and other presenting signs and symptoms that will assist the advanced practice nurse in making an accurate diagnosis so as to provide appropriate patient management. Key words: echocardiography, pericarditis, pericardial effusion, pericardial tamponade, tachycardia USCULOSKELETAL COMPLAINTS different diagnosis than one would expect are commonly seen in the quick with back and shoulder pain. Mcare (QC) and emergency care setting. Having a keen awareness of not only CASE FOR REVIEW the patient’s complaint but also the vital signs and other presenting signs and symptoms are A 39-year-old man presented to the emer- of extreme importance. In the case presented gency department (ED) with a complaint of in this article, the provider’s recognition pain in the upper back between the shoul- of abnormal vital signs led to a completely der blades for 1 week. He had been seen by his primary care provider 10 days before com- ing to the ED and was given an intramuscular Author Affiliations: School of Health Sciences, The Richard Stockton College of New Jersey, Pomona (Dr injection, hydrocodone and acetaminophen Bradbury-Golas), Shore Memorial Hospital, Somers (Vicodin) and cyclobenzaprine (Flexeril). The Point, New Jersey (Dr Campo and Mr Chiccarine). patient reported that a chest radiograph was Corresponding Author: Kathleen Bradbury-Golas, negative for infiltrates. The patient reported DNP, APN, NP-C, ACNS-BC, School of Health Sciences, increased severity of symptoms prior to the The Richard Stockton College of New Jersey, PO Box 195, Jimmie Leeds Rd, Pomona, NJ 082410 (Bradbury- ED visit. The pain radiated to the left shoul- [email protected]). der. This patient was assigned an Emergency 127 LWW/AENJ TME200069 April 26, 2010 11:12 Char Count= 0 128 Advanced Emergency Nursing Journal Severity Index score of four and was triaged Gastrointestinal. No masses. Bowel sounds to the QC area of the ED. in all four quadrants. Nontender, nondis- The patient’s past medical history was sig- tended abdomen. nificant for gastroesophageal reflux disease, Genitourinary. Unremarkable. and current medications include lansoprazole Pelvis. Unremarkable. (Prevacid) 30 mg daily, hydrocodone and ac- Extremities. Unremarkable. etaminophen (Vicodin), and cyclobenzaprine Musculoskeletal/Extremities. Bilateral (Flexeril). paraspinal tenderness—thoracic region. No The patient denied any food or medication spasm, costovertebral angle tenderness, allergies, unsure of last tetanus immunization, or limited range of motion. Strength 5/5 smokes a half a pack of cigarettes daily, drinks bilaterally. alcohol three to four times a week, and de- nied illicit drug use. Significant family medical Neurologic. Motor and sensory normal. Deep + history included a father who had received a tendon reflexes were 2 bilateral ankles and = coronary artery bypass graft at 78 years of age. biceps. Glascow Coma Scale score 15. Cra- nial nerves II–XII grossly intact. HISTORY OF PRESENTING ILLNESS Psychiatric. Unremarkable. Emergency department course The patient presented in no apparent distress but is complaining of increasing thoracic back The provider ordered the following: pain radiating to the left shoulder. The pain Cervical and thoracic spine plain was described as sharp and increased with left radiographs—three views arm movement. There was no numbness to Computed tomography (CT) chest (to rule the left arm and fingers. The patient has ex- out aortic dissection) perienced shortness of breath the day before 12-lead electrocardiogram (ECG) arriving to the ED. Heart monitor Laboratory testing PATIENT ASSESSMENT Basic metabolic panel Complete blood count The patient presented awake, alert, and Sedimentation rate oriented. Vital signs are as follows: heart Troponin rate, 124 beats/min; blood pressure, 128/82 PT/INR/PTT mmHg; respiratory rate, 20 per min; tempera- Medications ◦ ◦ ture, 36.9 C (98.4 F) orally; and pulse oxime- Ketoralac (Toradol) 30 mg intravenous try, 97% room air. Normal saline (0.9%) 500 ml/hr followed by Skin. Warm, dry, and pink. 100 ml/hr The results of the diagnostic testing are as fol- Head, eyes, ears, nose, and throat. head nor- lows: mocephalic, pupils equal, round, reactive to light and accommodation, extraocular move- ECG. Sinus tachycardia with nonspecific ments intact, free of icterus and pale conjunc- T wave abnormality in the anterior leads tiva. (Figure 1). Ears, nose, and throat/mouth unremarkable. Cervical and thoracic spine. Normal exami- nation. Neck. Supple no masses, lesions, or lym- CT chest. No aortic dissection or dilatation. phadenopathy. Full range of motion. Cardiomegaly with pericardial effusion up to Chest/respiratory lungs were clear to auscul- 1.2 cm linear atelectasis or infiltrate at lung tation in all fields. No rhonchi, wheeze, or bases. Trace pleural effusions (Figure 3). rub. CT abdomen. Prior cholecystectomy and ap- Heart.S1–S2 with no murmurs, gallops, or rub pendectomy. Abdominal aorta normal. Mild were auscultated. splenomegaly. LWW/AENJ TME200069 April 26, 2010 11:12 Char Count= 0 r April–June 2010 Vol. 32, No. 2 Getting to the Heart of Back and Shoulder Pain 129 Figure 1. Initial electrocardiogram. Figure 2. Computed tomography angiography chest emergency department. LWW/AENJ TME200069 April 26, 2010 11:12 Char Count= 0 130 Advanced Emergency Nursing Journal Figure 3. Initial chest radiograph. Complete blood count. White blood cell Initial chest radiography was repeated 16.7, hemoglobin 14.5, hematocrit 43.2, and twice during admission showing bilateral platelets 548. pleural effusions and cardiomegaly (Figure 3). Basic metabolic panel. Within normal limits. Workup for autoimmune disease and human Sedimentation rate.19 immunodeficiency virus was negative. Lyme titer was negative. Blood cultures were nega- PT/INR/PTT. 11.4/1.1/29.6 tive. Repeat echocardiogram 3 days after ad- Consultation. A cardiology consult was initi- mission showed improvement. Medications ated and stat bedside noninvasive echocardio- included nonsteroidal anti-inflammatory pain gram was ordered. The result of the echocar- medication, a proton pump inhibitor for his- diogram was circumferential pericardial effu- tory of gastroesophageal reflux disease and sion measuring 1.2 cm considered to be small a β-blocker for tachycardia. The patient was to moderate; mild concentric left ventricu- discharged 5 days after admission with the lar hypertrophy. The aorta, bilateral atria, and discharge diagnoses of (1) pericarditis with ventrical were normal size. Left ventricular pericardial effusion, resolved; (2) left shoul- systolic and diastolic functions were normal. der pain possibly secondary to pericarditis, Ejection fraction was 65% and all valves were resolved; (3) tachycardia; and (4) gastroe- normal. sophageal reflux disease. ED Patient Management ANATOMY AND PHYSIOLOGY This patient was administered levofloxacin OF THE PERICARDIUM (Levaquin) 500 mg intravenously and ibupro- fen 600 mg orally. The patient was admitted to The pericardium consists of two layers that the hospital for repeat echocardiograms and envelop the heart. The visceral layer, or epi- further treatment. cardium, is single layer membrane composed LWW/AENJ TME200069 April 26, 2010 11:12 Char Count= 0 r April–June 2010 Vol. 32, No. 2 Getting to the Heart of Back and Shoulder Pain 131 of mesothelial cells that adhere to the my- Table 1. Causes of pericardial effusion ocardium. The parietal layer is composed mainly of collagen and elastin fibers. The Viral, bacterial, fungal or parasitic infections two layers are separated by a potential space Idiopathic inflammation (about one third of that can contain up to approximately 50 ml cases) of serous fluid. The parietal pericardium at- Inflammation following heart surgery or taches to the diaphragm, sternum, and other myocardial infarctions (Dressler’s structures by ligaments that ensure a relatively syndrome) fixed position of the heart. The structures Autoimmune disorders, such as rheumatoid are innervated by the mammary artery and arthritis or systemic lupus erythematosus phrenic nerve (Braunwald, Zipes, Libby, & Uremia due to kidney failure Bonow, 2004; Marx, Hockenberger, & Walls, Hypothyroidism 2010). Human immunodeficiency virus /acquired immunodeficiency syndrome The pericardium has numerous functions. Metastasis from lung cancer, breast cancer, These functions include lubrication of the leukemia, Hodgkin’s disease, heart, heart position, prevention of infection non-Hodgkin’s lymphoma and overdilatation, atrial
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