Unexpected Outcomes

My apologies to all my readers: it's been quite some time since I sat down and wrote out a story, patient interaction, or lesson learned. Between recovering every other week from the next cold patients have given me and hanging out with Aaron, I've let time get away from me.

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Mr. COPD Strikes Back

Do you remember Mr. C (see last story on the blog entry, "plays well with others") ? He was the gentleman (I think I'm being very generous calling him a gentleman) who was hospitalized with respiratory failure and between gasping for breaths would ask me to marry him. We discharged him shortly after I posted the entry about him and he was back the very next day in even worse condition than before. He was unresponsive and couldn't breath without his BiPAP. If he tried to take it off, his oxygen saturation would drop almost instantly. Watching him struggle to breath was painful. He was having to use his accessory muscles, but even so, was very fatigued and would only take a voluntary breath about six times a minute. For days, he was not eating or drinking anything and wasn't even asking for his pain medications. He even asked one of the nurses what would happen if he kept his BiPAP off and how long it would be before he passed. I could tell he was terrified of dying, yet tired of the struggle and it seemed as if he was giving up.

We thought he was going to die and even went so far as to have the discussion with him that he wouldn't be with us much longer and asked if he understood, which he said he did. We stopped all the necessary medical interventions and put him on "comfort care". I began feeling very sorry for him again. His sons were called repeatedly and told they wouldn't have much time with their father and yet, they didn't come to visit. Here was a man in his early sixties lying half-naked in a hospital bed stripped of his dignity, hooked up to IVs and breathing machines, dying alone. I can't think of anything much worse. Part of me wanted to go in and sit with him just so he wouldn't be alone.

The day after we put him on comfort care, I went in to see him. Miraculously, he was better! His breathing was no longer labored, he had eaten breakfast, and was even talking to me and asking for his pain medications. Every day for the next week he made small steady improvements, but still required his BiPAP and didn't quite seem his feisty self until one morning when one of the nurses told me he called her an asshole and 15 minutes later he asked when we were going to get married. He was back.

We discharged him home two days ago in the best condition I've ever seen him in. As I was leaving his room that morning I asked him that the next time I see him, that it would not be in the hospital. He told me it was a deal and then asked, "So, you still haven't told me when we are getting married. What do you say?"

I gritted my teeth and replied, "You'll have to get through my dad first."

I didn't wait for a reply, but as I walked down the hall I heard him say, "Huh, you don't think I could run faster than him do you? Well, I guess you are probably right..."

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Making a Diagnosis

Mr. Sinusitis came in to clinic last week because he "just couldn't shake this sinus infection". He'd been seen the week previously for sinus congestion and had been given a Z-pak and told to follow up if things didn't get better.

Before I entered the exam room, I flipped through his chart and saw that he was a 71-year-old man with no significant medical problems. Sure, he's had his share of bone injuries and a couple of surgeries for those, but otherwise, he had no diagnoses and took no medications. I tried to think about what I'd tell him about his unresolving sinus symptoms and I was drawing a blank. I'd resolved to the typical medical student thing of asking a bunch of questions he'd already asked before and then ending the interview with something like, "huh, well I don't know what to tell you; we'll see what the doctor thinks, but I have a feeling you have a viral infection. There's a lot of this stuff going on right now and it might just take you a bit longer to get over it and antibiotics don't usually help."

I opened the door, introduced myself, took a seat and started in with the questioning: when did this start? has it gotten any better? worse? what have you done to treat it? As he started answering my questions, I got the feeling this wasn't a sinus infection and I broadened my differential. They teach us that you should always go back to the history and physical exam when trying to pin down a diagnosis and it seemed that his history was not that of a typical acute onset sinus infection.

With more thorough questioning I learned that his symptoms started over three months ago and consisted of no only upper airway congestion, but also daytime sleepiness, fatigue, shortness of breath, dyspnea with mild exertion, orthopnea, leg swelling, palpitations, and an irregular heart beat (which he apparently had been told he had last year). These symptoms set off red flashing lights in my mind: this man has congestive heart failure! As I finished up the history and started in on the physical exam, I began thinking about the things I might find if he did in fact have heart failure: crackles on his lung exam, possibly an irregular heart beat with or without a murmur, elevated neck veins, hepatojugular reflux, lower extremity edema. I started by listening to his heart: it was irregularly irregular (in medicine, that is pathognomonic for atrial fibrillation) with a 3/6 holosystolic murmur at the cardiac apex (pathognomonic for mitral regurgitation) which supported my diagnosis of CHF. His lungs were clear, neck veins flat, and there was no hepatojugular reflux, but he did have pitting edema in his legs and a negative HEENT exam (which speaks against a sinus infection as a cause of his symptoms).

I left the room and look for Dr. Gunther who was in with another patient, so I grabbed Debbi, "can you please get an ECG on Mr. CHF (previously known as Mr. S)?"

When Dr. Gunther was done with the other patient, we went into the room and I presented my findings and offered my assessment and plan, "I think he has heart failure. I've already asked Debbi to get an ECG and I think we need to send him for a chest X-ray and an ECHO and get some labs today."

Dr. Gunther agreed with my findings, handed me the lab slip to order the tests I wanted, and made some calls to get him scheduled for the CXR and ECHO. Debbi came in with the ECG: sure enough, he was in A. fib. We explained to Mr. CHF and his wife what we thought was going on but said we couldn't be sure until we had some of the test back. We sent them to the hospital to get the CXR and ECHO and asked them to come back to clinic afterwards. They returned late that afternoon, tests in hand. The CXR showed an enlarged heart. The ECHO showed a markedly reduced LV ejection fraction, mitral and tricuspid regurgitation, but no structural wall or valve abnormalities. His BNP was elevated. In English, he had congestive heart failure.

Dr. Gunther broke the bad news and talked him through the diagnosis. He completely distanced himself, however: he stopped making eye contact and only replied with grunts, slight head nodding, and shoulder shrugging. Clearly he was upset and intentionally not listening. We shifted our attention to his wife who was fiercely taking notes.

Dr. Gunther asked me what I'd like to treat him with. "I guess we should start lasix for the edema and he'll probably need some KCl with that as well so he doesn't become hypokalemic...I'd like to give him digoxin for A. fib...Maybe a beta-blocker for rate control...I guess we should start and ACE-inhibitor as well...he should stop drinking as well (he drinks 4-5 gin and ginger ales a day), so he might need some ativan for 'his nerves' [this was code for alcohol withdrawal symptoms]."

"Very good, Emily." Dr. Gunther began writing out the prescriptions. Then I realized that I made my first bonafide diagnosis! I took the history. I performed the physical. I ordered the tests. I came up with a treatment plan. This was a new feeling for me and I surprised myself that I knew what to do. I was very sad for Mr. CHF and his new devastating diagnosis, don't misunderstand me, but I felt a sense of fulfilment and validation that I was actually doing something to help him.

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As scientific and exact as medicine is, there are always unexpected outcomes, whether it be Mr. COPD making a miraculous recovery or Mr. CHF being told that his sinus infection is in fact heart failure. I guess it's the uncertainty that keeps things interesting and provides the unending challenges that physicians must work through.