Wednesday, October 05, 2005

Achy Breaky Heart

A crazy thing happened today. I saw the most patients I have ever seen in a single day (n = 28) and I left the clinic at 5:00 PM on the nose. It was divine. I am in a state of joy bordering on beatitude.

I did, however, send a patient to the emergency room. I like to have both the calm and the storm, I guess. Here is why this man had a ride with the paramedics. He had chest pain, dyspnea (worse when supine, so I guess technically it was orthopnea) and had diagnosed left-sided heart failure last year that resulted in him receiving a pacemaker. His father died from heart failure at age 54. And did I mention that, despite treatment with 80mg TID of Lasix, he had urinated exactly once (4 ounces – he actually measured) in 48 hours?

Now, I must confess that I partially sent him because I was scared, the only provider in the office this afternoon, and I knew that his history and symptoms were both serious and beyond my ability to care for. I think that it was the right decision. He was overweight and his exam was unremarkable, but as I’ve previously mentioned, ausculatory exams on obese persons are exceedingly difficult. Did I hear crackles? I did not. Nor did I hear normal breath sounds; I heard faint breath sounds and faint heart sounds. His abdomen was huge. Was he holding fluid in there? I don’t know, but the doctors at the emergency room will.

For those students/new practitioners who are familiar with the lower extremity edema/DOE/chest pain presentation of heart failure, please allow me to point out that this picture often points to right-sided failure. Left-sided HF is sneakier. I was too freaked out to think about that until the paramedic mentioned it, leaving me to feel like a huge jackass. Whatever – my ego will survive and I am the wiser for it.

Here are some tidbits to refresh and/or inform:

Signs of HF include:
Cough with or without frothy sputum (yeah – gross)
Abdominal pain +/- nausea
Constipation (who knew??)
Exercise intolerance (I’d hazard a guess that 90% of my patients have this as they never exercise)

Symptoms of HF include:
Fine crackles, generally bibasilar
Pallor or cyanosis

However, Uphold & Graham point out that “[in] left-ventricular systolic dysfunction, signs and symptoms are not reliable indicators or cardiac functioning; patients with severely impaired ventricular performance may be completely asymptomatic until they overexert themselves…” Thus, the ED visit today.

Which reminds me… the paramedic asked me, as I was standing there feeling like a buffoon, if any of the patient’s medications were constipating. A) I don’t fucking know for certain but probably not and B) constipated or not, homeboy has essentially not taken a leak in 2 days and has both a personal and family history of cardiac disease. Can we deal with the poop later, please? When I’m thinking of priorities, it goes something like this:
1) heart failure
2) poop

Twenty-eight patients. I think my days on easy street will be coming to an end. I exceeded my goal – set by the clinic manager - of 22-25 patients/day. Crap.

1 comment:

Tiffany said...

Another tidbit of heart failure info...the young frequently present very differently from the elderly. I'm a CNM but am well versed in all things heart failure as my husband has recently received a heart transplant for end-stage heart failure and had an LVAD prior to surgery. He's now 45 but was diagnosed with DCM at 33. Good for you, for sending him into the hospital! My husband's family practice docs futzed around for a week trying to diagnose him with hepatitis before they ordered an echo and discovered his 20% ejection fraction and atrial clot. I was two weeks away from graduating from nursing school. My husband's timing has always been stellar like that.