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First Year NP

Heart-Wrenching Heart Patient

Published April 25, 2013 9:42 AM by Anne-Marie Gitchel
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 patient.

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 all.

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 given.

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 patient's heads.

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 appointments. 

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.


A Lasix drip is an old-school way to diurese someone. I haven't seen it done in years, but it did work. Really have to watch electrolytes and they have to have reasonable renal function.  

Carolyn , CNP May 9, 2013 3:05 PM

Great article! Please keep me posted on her outcome. What the heck is a lasix drip? I've never heard of it. That physician just didn't get it. No wonder patients don't understand their own conditions.

Romina, Urgent Care - FNP-C May 6, 2013 6:27 PM
Glendale AZ

Great article,

Thanks for sharing. Would love to know the follow up? I have never heard of a Lasix drip!!!!


Teresa, Internal Medicine - RN MSN FNP-C May 2, 2013 7:46 PM
Longbeach MS

What's wrong with this picture?  The last statement should have said: To be the advocate for patients whose physicians just don't get it.

Is it posibble that physicians don't know what they don't know?

Paula, PA-C May 2, 2013 9:24 AM
Watersmeet MI

Hello and thank you for your article. I recently began doing health risk assessment on members of an insurance company in the county where I live. Most of the patients are between the ages of 65-90yo with multiple chronic conditions, esp heart confitions. I have seen pts like your, although not quite as severe & have made recommendations to them. Unfortunately, because I'm not the PCP, a part of his practice or have any rapport with these patients, Im not always certain they "get it". Basically I collect subjective & objective info (pe) and submit with the proposed care plan. Whether it gets done or not I only pray.

    Please continue to submit your articles concerning special cases like this one. They are very helpful to providers like me who meet these pts before they hit the front door of the ED. Many of us who are out in the field with no direct collaboration of the pt's group or physicians encounter similiar situations and just need to give the pts & caregivers advice. Sometimes,  i'm told the doctor never explains things or he doesn't have time. There is a grain of truth in what I'm hearing, but nevertheless, I'm compelled to do what I can while i can. What little advice I give these patients they truly appreciate. Thanks again


Beatrice McIver,  PA-C

Beatrice McIver, Occ med/Fam pract - PA-C, Concentra Medical May 2, 2013 9:22 AM
Birmingham AL

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