Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Saturday, June 23, 2007

Sometimes I Hate Being Good

I saw a little old lady -- 87 pounds soaking wet -- for a gyn exam. We'd done the rest of the physical when I first met her last month, and everything was fine. A little hypertension, well-controlled with minimal meds; nothing else.

It had been about 8 years since her last pap and she was delighted to finally be having it done again. Although usually very conscientious about her health, she had been caring for her husband for the last few years. After his death several months ago, she was ready to take care of herself again.

She felt great. No complaints at all. So today I was just playing gynecologist: weight, BP, thyroid, breast, abdomen and pelvic exam. (She'd had eight kids; no problems there.) Nothing to it.

Silly me. I had to take her blood pressure.

Listening to her pulse between the systolic and diastolic (a nice 132/70) I thought, Man, that's fast. Kind of irregular, too. Felt the pulse at her wrist: surprise! Fast and irregular. I even took a quick listen to her heart. Shock of shocks: fast and irregular.

The gyn exam was perfectly normal for age, but -- silly me -- I just had to go get my EKG machine and grab a quick tracing: rate 150, irregularly irregular; nary a P wave to be found. As I could tell just from taking her blood pressure, she was in atrial fibrillation.

So then I had to go explain to this perfectly healthy, asymptomatic little old lady (and the daughter who brought her) that I wanted her to go over to the ER and be admitted to the hospital for a bunch of tests and drugs and maybe a little cardioversion. (No, I didn't use that word. I said, "They may decide to put you to sleep for a minute and give your heart a little electric shock to see if they can get it back into its normal rhythm again.")

They had a busy day planned, and here I had gone and ruined it for them.

Oh well.


At Sat Jun 23, 12:03:00 AM, Anonymous Anonymous said...

Hi, just curious here.

What would cause that and what would have happened if it had not been caught?

150 is pretty high, why wouldn't something like that be felt?

At Sat Jun 23, 07:34:00 AM, Blogger #1 Dinosaur said...

1. She could have had a stroke, and 2. some people have no symptoms from the fast heart rate at all.

More info here.

At Sat Jun 23, 08:20:00 PM, Blogger XE said...

Just curious...

"a nice 132/70"

Nice? Ummm... the diastolic is fine, but isn't that systolic kind of high?

At Sun Jun 24, 02:34:00 AM, Blogger Maurice Bernstein, M.D. said...

With regard to stroke, sometimes the stroke can be precipitated in an atrial fibrillation patient who is attempted to be cardioverted while in a state of none or inadequate anticoagulation. I had this happen to my patient once, when the cardiologist she was seeing failed to check her prothrombin time just prior to cardioversion. After the heart was suddenly returned to a normal rhythm, the atrial fibrillation had stopped with the shock, she immediate developed a mild cerebral infarction which fortunately cleared over the following few days. ..Maurice.

At Sun Jun 24, 07:46:00 AM, Anonymous Anonymous said...

Cardioversion? In an asymptomatic patient with AF of unknown duration? I would have started the patient on warfarin and scheduled an elective echocardiography exam.

At Sun Jun 24, 08:12:00 AM, Blogger #1 Dinosaur said...

Xavier: Technically an SBP of 130-139 is considered "high normal." That's the new designation; it used to be "normal" up to 140. It also goes up with age, so in an 80+ y/o it's pretty darn ok.

Magda: You're braver than I. I sent her over to the hospital where they admitted her, anticoagulated her and got her converted to sinus rhythm with medications. I only mentioned cardioversion to her so that if they decided to do it, it wouldn't come out of left field. I don't know what the standard of care is in your area, but around here they usually admit for new afib. (Not an implied criticism at all; we could very well be overly cautious around here.)

I was just proud of myself for the diagnosis, and didn't really intend to address treatment/management.

At Sun Jun 24, 08:44:00 AM, Anonymous Anonymous said...

The standard of care "in my area" is pretty much the same as in the US. As UpToDate has it:
"In particular, patients with AF of more than 48 hours duration or of unknown duration (..) may have atrial thrombi that can embolize. In such patients, cardioversion should be delayed until the patient has been anticoagulated at appropriate levels (INR 2.0 to 3.0) for three to four weeks or shorter term anticoagulation if screening transesophageal echocardiography has excluded atrial and atrial appendage thrombi."

We usually start anticoagulation and perform cardioversion after the patient has had INR 2.0 to 3.0 (documented at least weekly) for 4 weeks. Of course transesophageal echo can be performed if there is a more urgent indication but it is not 100% reliable in excluding thrombi so I would prefer to wait& anticoagulate in an asymptomatic patient.

I am always interested "how they do it" in other countries - that is one of the reasons I read (and enjoy) your blog.

Have a nice Sunday :-)

At Sun Jun 24, 08:54:00 AM, Anonymous Anonymous said...

And let me add I learn a ton just reading your blog... looking forward to every new entry.

As to the lady, you may have ruined her day... and you may have saved her from some very ugly consequentions of her A-fib...

At Sun Jun 24, 09:49:00 AM, Blogger Dr. Smak said...

I had essentially the same patient last week, and managed her outpatient by starting her on a beta blocker and coumadin. However, her rate was 110, and she was a bit younger than yours. I'll see her daily until I get her rate under control.

A rate of 150 definitely deserved a trip to the ER.

And for what it's worth, I've lost some sleep over her, as I always do when I handle this outpatient. This is one of those sometimes-I-do-sometimes-I-don't situations.

At Sun Jun 24, 09:52:00 AM, Blogger Dr. Smak said...

PS Same as you, I caught it on the blood pressure. My nurse (who usually has diagnosed new onset Afib and has the EKG on the chart before I hit the room) put her down as a rate of 84. She was kicking herself the rest of the day.

There's nothing like a good nurse. We all have "off" days.

At Sun Jun 24, 11:20:00 AM, Anonymous Anonymous said...

Dino...Congrats, you probably saved her life. Well, more like, most likely saved her did save her life. A good day's work for you. Hope you treat yourself to something wonderful this weekend, you deserve it:)

At Sun Jun 24, 05:02:00 PM, Blogger The Tundra PA said...

Whew! I was teeth-grittingly prepared to learn that you discovered some horrendous fungating mass in her vagina that used to be her cervix.

Good work doc!

At Sun Jun 24, 05:41:00 PM, Blogger #1 Dinosaur said...

TPA: Yeah, I hate when that happens too.


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