- Hey, guys, welcome to another episode
of the Wednesday Checkup.
Today, I wanna tell you about a really interesting
patient encounter I had just the other day
and then we're gonna follow up that story
with one of my favorite segments, Mail Time.
You ready?
(whooping)
(mellow music)
My nurse rooms the patient, takes all the vitals,
brings all the information,
including the chief complaint to me.
Tells me that the patient has normal vital signs,
normal blood pressure, pulse, high 90s.
That he's a mid 60-year-old male.
That the breathing rate is normal.
And that the patient's chief complaint
is that there's this redness surrounding the right foot,
that the patient is worried about,
that the antibiotics haven't really,
that they haven't really seen
an improvement in the redness of the right foot,
despite using antibiotics in the last 48 hours.
Prior to walking into the room with the patient,
I did look at the electronic health record
and found out they have
an extensive list of medical conditions
and are take a lot of medications for them.
Hypothyroid, osteoporosis,
diabetes type 2, high cholesterol, atrial fibrillation,
so I know that this patient does have medications onboard
and other conditions at play.
It's important for me as a doctor to check
that before going into a room
so that I can see how maybe those illnesses
and those medications can be factoring
in to the current problem.
After hearing the story about the foot,
I asked the patient if there were any other complaints.
And I generally have a list of
what we call a review of systems,
where I ask a few general questions
just to see how the patient's doing overall.
Constitutional symptoms like fever, fatigue,
unexplained weight loss,
then we have the cardiovascular ones,
palpitations, chest pain,
then with the respiratory ones, shortness of breath.
You sort of get the idea.
The patient did mention that he felt
a little bit more short of breath than usual.
He attributed that to the pain
and discomfort from his right leg.
That he thought maybe he wasn't sleeping as well
and there were all these sorts of explanations
he had in his mind for why that was happening.
So I listened to the patient's lungs,
crystal clear, no problem.
When I listened to the patient's heart,
I hear something that I didn't expect to hear.
The patient was having an irregularly irregular rhythm,
meaning that it was an irregular rate,
that is was above 100,
and it was an irregular rhythm,
meaning that it didn't have a consistent beat to it.
Ba-boom, boom, ba-boo-boo-boom, boom.
That is essentially the beat that we would hear
if a patient has atrial fibrillation.
Now I know this patient has a history of that
so it makes it a little bit more easy for me
to expect to hear that.
But a patient who has atrial fibrillation actively,
at a fast rate is dangerous.
Reason being is the heart doesn't like to be beating
very rapidly for a long period of time.
At rest, your heart rate should be
somewhere between 60 and 100.
However, my patient was beating somewhere in the low 100s
when I listened and I checked their pulse.
I asked the patient,
"Have you felt any palpitations in the last few days?"
Meaning that they feel like their heart's racing
or beating outside of their chest.
That's a very common way to explain it.
And the patient says to me,
"You know doctor, the last few days,
"I did feel a little bit
"and I wasn't sure if it's my AFib,"
the atrial fibrillation, "kicking in.
"But it went away, so I assumed nothing of it.
"Is that okay?"
Let me do something, let me get an EKG
just to see how your heart is doing,
how fast is it beating,
confirm that this is fact AFib,
and we'll move on from there.
And we sort of put the foot issue to the side
because A, he's actually being treated for it,
and B, the more concerning issue for the time being
would be the heart.
Upon getting the EKG, we found out
that my physical exam was correct
and the patient was having AFib.
And he was having AFib with RVR.
I know that's a mouthful.
AFib is that atrial fibrillation
where the top of the heart beats
irregularly at an irregular rate.
But then his ventricles,
as a result of having those excess beats,
was also beating very quickly.
That's the lower portion of the heart
that actually pumps out blood to the rest of the body.
His heart was working very hard
in order to maintain this rhythm.
But this isn't normal.
My patient's at rest, his heart
shouldn't be beating that quickly.
Upon further review of that EKG,
I found that he was having segments
of what's known as ST depressions.
And what ST depressions, specifically on an EKG signify
is that the heart isn't getting enough blood
and it's suffering.
It's actually being choked out.
We call this a type 2 MI which ones a type 2 heart attack.
When the heart is beating so fast
that it's not getting enough blood
because it's being overworked
and there's actual damage to the muscle tissue of the heart.
So I told him that we have to call 911
and we have to get him sent over to the hospital
in order to contain this rate,
slow the rate down,
and then figure out what our long-term plan is gonna be.
Now this was very stressful
because the patient started getting emotional,
they started getting worried and upset
because they thought they were coming in for their foot,
but here we are, diagnosing them with a heart attack.
My patient ended up going to the emergency room.
They gave him IV medications.
They made sure that the rate subsided,
that the enzymes that were leaking from the damaged heart
started going down and the heart was improving.
And once that started happening,
they had a cardiovascular doctor see the patient
and decide what the plan wanna gonna be moving forward.
And part of that was to increase
the dosage of one medication
and decrease the dosage of another.
And then have them follow up in one week
with that same cardiologist.
The point of this being
is that as a doctor, you never know what do expect,
especially at a family medicine office.
I had a patient on my schedule for an infected foot,
and here I am, diagnosing him with a heart attack
that they were walking around with.
They actually walked a few blocks to my office.
A mistake I see a lot of young doctors make
is to get pigeonholed into a diagnosis.
They see a red, swollen foot on their screen.
They only look at that body part
and they say, "Okay, well here's a diagnosis for this,"
and they forget that there's a whole person
sitting in front of them.
It's important to take that whole person
to consideration when treating a patient.
Yes, the complaint is about an infected foot,
but the real concern was with my patient's heart
and the only way I could find that out
is through a thorough history and physical exam.
Had I not done those things,
just looked at the foot, said, "Okay, the foot's improving,
"you know, keep taking your antibiotics,
"let's have you follow up."
I would have been doing a huge disservice to my patient.
We have to treat the human sitting in front us
and not the ailment,
or not the complaint that they're bringing to us.
The more you can do that as a doctor, as a person,
as a police officer, it really doesn't even matter,
the better you're gonna fair
and the better the person sitting
in front of you is gonna fair.
Let's have some fun and open some packages
via Mail Time, courtesy of my mail bag.
West Orange, New Jersey, that's not too far.
(bag crinkling)
Oh, these are gonna be cuff links
because I can tell from the cuff link box.
Ooh.
These are
dope.
These are little stethoscopes.
Ooh, look at this little checkerboard tie.
If it matches, you gotta wear it.
Whew.
Easy work.
Thank you for your wonderful gift.
I think I look pretty fly
and I can't wait to wear these cuff links.
Fort Walton Beach, Florida.
(gasping)
Snickers!
(gasps)
Did you get Bear his favorite toy?
No joke, this is Bear's favorite toy.
Little squirrels that you put in here
and then he has to get them out.
Bear, I have a gift for you.
Oh, they make noise.
This is legit, Bear's favorite toy.
He's gonna lose his mind.
Oh, it's a mug.
Aw, me and Roxy sitting side by side.
How did you do this?
Husky Dad, me and Roxy hanging out.
Thank you, family.
Okay, this one's from Texas.
Whoop!
Whoa.
Swarovski pens,
with my name on them.
But the only thing is,
I'm not a DO
and MD,
I'm just a DO.
Problematic?
This is from Hungary
and I've been to Hungary many of times.
Not many of times, I've been there twice.
I imagine this is gonna be a drawing
'cause it's with some really heavy cardboard.
Here, let's see.
"Dear Mike, I couldn't decide, so I did both.
"Hope you like it, best regards."
What?
This is by far the best drawing
I've ever seen of me in my life.
This is pencil, folks.
Is this ridiculous or what?
- Wow. - Dude, these are amazing.
I'm gonna have these framed.
I don't know where I'm gonna put them
because it's kind of awkward
hanging pictures of yourself in your own house,
but these are amazing.
Like, this looks like me.
Beau Smith or Bea Smith,
please, send me your Instagram.
I wanna put this on my story
and share this with the world.
Your art is amazing.
I mean, like you can't draw better then that.
This is from Ohio.
Okay.
Okay, here we go, we got socks.
Get outta here!
Socks with Roxy and Bear's face on them.
Come on now, chum on.
I'm gonna wear these to work
and people are gonna judge me
and I don't even care at all.
Thank you, Kenyatta, very much appreciated.
Stay being an awesome nurse.
"I've sent you a T-shirt I make at our small family farm.
"I guessed you wear a large or extra large
"so whichever one doesn't fit,
"feel free to do whatever you want with it."
Okay, this is a very interesting shirt.
Support your local beekeeper, I'm down with that,
but why is the bee throwing up?
(retches)
Fun fact, all my videos are now captioned
in English and Spanish,
so click here to check this one out
and have good laugh.
As always, stay happy and healthy.
(cheery music)