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:
DOE/PND/orthopnea
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
S3
Edema
JVD
Tachycardia
Hepatomegaly
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.