Heart-Wrenching Heart Patient
I had my first jaw dropping patient last week. You know, working
in cardiology, you see a lot of the same thing. Acute coronary syndrome, atrial
fib, heart failure...Turn 'em and burn 'em, that's my motto. Thursday, I had my
first patient that I was completely side-bombed over.
That day, an 86-year-old female presented to the ED for shortness
of breath. She's admitted to the hospitalist service. Labs are drawn and the
patient has a BNP of over 2000. She arrives to the floor and a cardiology
consult is placed. I quickly make my way to the room to do the consult and when
I initially begin to talk with the patient, everything seems to be "normal."
Then the story unravels.
The patient has been diagnosed with diastolic heart failure for years.
She's never had a true exacerbation. She saw her cardiologist in September for
her annual follow up. At that time, the patient had generalized complaints of a
minor increase in shortness of breath, but there were no medication changes
instituted at that time.
In December, the patient was having more shortness of breath and
also began to feel quite fatigued. Her husband had begun to notice some
physical changes indicating she was retaining fluid. They decided at that time
to see her primary care physician, who drew a complete blood count on the
She was severely anemic with a hemoglobin of just over seven.
Since there were no obvious signs of bleeding, he set the patient up for an
upper and lower endoscopy. No GI consult; just set up the procedure. They both
were insignificant so the physician ordered five transfusions over the next 4
weeks and then left it at that. No follow up on it.
Let's fast forward about 4 months and get back to me interviewing
this patient and her husband. She is clearly uncomfortable while she is just
lying in bed. They tell me that she's progressively become more swollen over
the last 4 months but they don't know how much weight she's gained because they
don't have a scale.
About 3 weeks ago, the patient became extremely fatigued and was
requiring a moderate amount of assistance with her activities of daily living
and for the last week, it was absolutely complete assistance with everything.
She couldn't move at all.
At this point, I've done my questioning of the patient and her
husband and I was still thinking this wasn't too crazy of a case. And then
comes my physical exam and where my jaw drops. I proceed with my cardiac exam
and realize that there is 1+ pitting edema where I place my stethoscope on her
chest to listen to her heart sounds, and mind you, I'm not pressing hard at
I have her husband assist me in getting her rolled over because
at this point, even just lifting her arms was a difficult movement for her. We
finally get her rolled over and the poor patient had pitting 3+ edema to her scapula.
This folks, is the perfect picture of, yes, anasarca.
She had 3+ pitting edema down her entire body. I couldn't get pulses
in her lower extremities. Her upper and lower extremities were cool to touch
and had a decrease in sensation.
So after I finish my exam, I talk to the husband a little bit
longer and then go to the dictation room with chart in hand. I managed to find
her cardiology clinic chart and start delving. This patient has managed to have
CHF for this long and has truly not had an exacerbation.
Please remember we live in Northern Michigan. There is a great
percentage of our population that is not highly educated. Unfortunately, the
socio-economic gap that exists has a huge impact on many of our patients truly
understanding their diagnoses and the lifestyles changes that need to be
enacted to ensure that they don't become exacerbated. And this patient is the
prime example of that.
They were not able to tell me the first thing about heart
failure. And this isn't at the fault of their outside providers. It's simply
because they just couldn't wrap their heads around the information when it was
You know that form that you do as a floor nurse asking a patient
what is the best way that they learn? You know. One of the many that you just
click boxes without really even asking the patient. This is one of the most
important questions that need to be asked. We need to know how to teach our
patients, or, to pound it (for lack of a more appropriate term) into our
I went into her chart to assess what medical therapy she was on
and what tests had thus far been ordered. I called the echo tech to find out
the "unofficial" results of her echo and was informed that they were unable to
do the test. They tried but the patient's excessive fluid level did not allow
for the ultrasound to be able to visualize the cardiac structures
appropriately. We had to wait.
The lasix drip had been going for a couple of hours (why the heck
a lasix drip, I don't know; don't get me started on that) and so now we were at
that time that I like to phrase "hurry up and wait." (Military background. Can't
help it.) So I made changes to her oral medications to ensure she was on the
most appropriate therapy for her heart failure, which is much more detailed
than I remember when I worked in a cardiac stepdown unit.
When I went in Friday morning, the patient looked better. She was
actually sitting up on the side of the bed. She needed some assistance but not
as much as she had been and she had diuresed about 2 liters. So we continued
that process over the weekend.
We had a newer hospitalist on service on Monday and I met up with
him to discuss the case. The patient had been severely anemic since December
and had come in to us anemic. She had continued to drop and over the weekend,
this had not been covered.
He said that this was chronic and I let him know that I was
concerned because the numbers didn't lead me to believe that it was an anemia
of chronic disease and that it had truly been worked up. He told me to focus on
the heart. Nice. Then he told me he wanted to discharge her, but was going to
wait one more day. Another jaw drop. She had diuresed over the weekend but she
still had 2-3+ pitting edema to her lower back and was still really weak. I
told him I thought that was being a little aggressive.
I guess my input went unheard. I had class the next morning and
when I rolled in after lunch, I learned that my patient had been discharged.
Yep. Discharged. I couldn't believe it. I spoke with the cardiologist that I
worked with and he said that he told him he thought it was a little early, but
the guy discharged her anyway.
So I did what I do best. Got fired up and started making calls. I
called the primary care office, the cardiologist's office and our heart failure
clinic. I got appointments set up and then I called the patient. I talked to
her husband and told him the importance of remembering what we talked about.
Remember to limit her fluids, and watch her salt intake and go to her
Now all I can do is sit back and pray that she makes it to her
appointment in 4 days. Pray that she doesn't end up back in the hospital and
pray that she is safe at home with her weakness. Not many patients really get
into my heart but for some reason, this one did. It's patients like her that
make me realize why I do what I do. To be the advocate for patients who just
don't get it.