Case 4- Racing Heart + Tired & Swole.
This week in clinic a 73yo male presented with a chief complaint of palpitations. He also reported swelling to his legs, generalized fatigue, and dyspnea on exertion.
Physical exam was notable for a rapid irregular pulse and lower extremity edema. EKG (shown below) revealed atrial fibrillation with a rapid ventricular response (~130bpm). There were also pathologic Q waves in leads V1 and V2, consistent with septal infarct.
Echocardiogram demonstrated the following:
Plethoric inferior vena cava (IVC)
Markedly depressed systolic function (poor LV function, decreased MV excursion/increased EPSS, etc.)
Thinning of the interventricular septum and increased echogenecity (findings that correlate directly with the patient's EKG evidence of prior septal infarct).
Labs were notable for normal blood glucose and evidence of renal insufficiency with a creatinine of 1.8.
To quantify his risk of stroke in the context of atrial fibrillation, a CHADS-VASC Score was calculated. His score was 4, placing him in "moderate-high" risk for stroke (~5% per year)
He was placed on the appropriate medications to decrease his pulse, minimize risk of future cardiovascular and cerebrovascular events, and address his symptoms. Close follow-up was arranged.
I would not argue that his case was extraordindary. It is arguably mundane (septal MI, afib with RVR, CHF with hypervolemia, and dash of CRI for good measure).
I would however argue that the care provided at our center in a small community in the mountains of rural Guatemala was quite extraordinary. In less than an hour, he received: physical exam, EKG, labs, echo, and appropriate meds. In my humble (albeit biased) opinion, that is
The above case is a tangible representation of our mission (see Mark 12:30-31) made manifest.
The other part of this particular case from which I derive considerable satisfaction is that this was not my case. I was not this patient's healthcare provider. He was evaluated and treated by my colleague, Dr. Dina. A few short years ago when Dina first joined our team she would not have been able to evaluate and treat a similar case with the competency and sophistication that she displayed in managing this case. By investing time and energy into the training of Dina, she has subsequently become a force multiplier in our work and our mission.