By far one of our more challenging patients has been an elderly woman that has usually had different symptoms every time she came in. Serious ones! I began to tell her story in Big Hearts and Everyday Catch. Well, she came in for another visit just 7 days after the last story ends. She had gained back 3kg of weight though she still looked quite gaunt. Her heart was in sinus rhythm but bradycardic (slow) at 55bpm. Her blood pressure held steady but high at 158/70. Concerned about what was going on with her heart we drew blood for labs. Her electrolytes were normal and her blood count fairly normal (hgb was barely low at 12.5) but her CKMB showed up as 19, CK low at 32, and LDH at 133. Still having cardiac issues but did not seem to be urgent. Heart failure currently somewhat controlled but the weight gain could be retained water. The doctor decreased her Atenolol dose and requested to see her back in a week.
Eight days later she returned with 2+ pitting edema and an additional 2kg weight gain, increase respiratory rate and work of breathing. She had been unable to keep any food down for the past 5 days and would vomit whenever she tried to eat. Her heart rate was 60, BP 139/72, and O2sat 95% on room air. We again drew blood and checked labs. Her CKMB was now 21 and her LDH 128. Not drastic but still a chance she could have had a mild MI (heart attack) that was now resolving. Or could her congestive heart failure (CHF) be worsening? The doctor added 20mg of Lasix, 10mEq of Potassium chloride, and Metoclopramide as needed for nausea and vomiting. She was to continue at the same dose of Atenolol and he wanted to see her back in another week.
Ten days later she returned, always with the biggest brightest smile for everyone and giggling easily, hugging and shaking hands with all. She had gained an additional 5.5 kg of weight, had 2-3+ pitting edema in legs and feet. She says that it goes down when she takes Lasix but then comes back shortly after. Per her daughter, the patient’s tolerance for exercise is decreasing, now needing more help to get around and more breaks along the way. She is not eating much at all but is experiencing bloating. Her cough has increased in frequency and it is now a very moist nonproductive cough. Uh-oh. Not a good sign at all. As we listened to her lungs she has diffuse rales throughout. Chest x-ray showed a positive pleural effusion and her heart size continues to increase. We drew labs and sent some off to an Australian lab to check her thyroid hormone levels. There is a chance that the thyroid may be contributing to these symptoms. The rest of her labs came back normal. The doctor increased her Lasix and Potassium. She is to continue her Atenolol dose and come see us if things change.
However, the doctor called the patient back in to the clinic one month later, as soon as he saw her lab results—TSH <0.8 (normally 0.3-3.5), Free T4 47.7 (normally 9.0-19.0), and Free T3 >46.1 (normally 2.6-6.0). This patient is in a hyperthyroid storm! The faulty heart valve discovered last July has likely helped along the CHF but the primary driver for her condition is a majorly overactive thyroid leading to what is known as a Thyroid Storm! Upon entering, she had her usual huge grin and big hugs and spryly stepped up on the scale. She had lost 7kgs of weight. Good. Likely water weight decreased. However, once we had her seated and connected to a monitor, her heart rate registered as 121-182 and irregular, a new development and not a good one! Her BP was 152/86. With a stethoscope I confirmed the irregularity and asked another nurse to please bring the doctor right away and then help me get a 12-lead EKG and rhythm strip. The patient’s temp was 38.6°C and she was quite warm to touch, a little diaphoretic (sweaty). She demonstrated shortness of breath (SOB) and increased work of breathing at rest and felt more comfortable with the head of the bed up a bit rather than lying flat. The EKG showed atrial fibrillation (or A-Fib…that is when the upper chambers of the heart beat super fast but the lower chambers respond only at their normal rate). We gave her 40mg Propranolol by mouth and started an IV and drew blood work. Her potassium came back low at 3.0 (normally 3.5-5.0) so we started a slow NS IV drip with KCL. We also gave her Heparin subcutaneously and Aspirin by mouth to help prevent a clot formation in her heart due to the A-fib. We also gave her Carbimazole to start decreasing the overactivity of the thyroid. She seemed to take all of this well. It was agreed that she would stay at the clinic until her heart rate was under better control. The Propanolol normally takes a few days to take effect but we didn’t feel comfortable sending her home in her present condition.
This patient speaks a little Tok Pigin (the trade language) but mostly in her tok ples (her village language) and had trouble at times following what she was being told. There were more than a few giggles on the part of the woman who was there with her as she tried to help ask questions and answer them. This spunky lady has quickly become one of my favorite patients to see in the clinic!
An hour after she’d arrived, her heart rate was down to 62-117, at times looking regular and other times irregular, still in A-fib. BP had dropped as well to 114/72 and O2sat stayed about 95% on room air. Her cough continued to be very frequent and moist. With her heart reaching the 60s and staying there a time, we quickly rechecked a 12-lead EKG and rhythm strip. It still showed A-fib, unchanged other than rate. We continued to monitor.
Within another 1-½ hours she had a large emesis of yellow bile and was continent of loose stools. She kept laying forward in her own lap while on the toilet and I had to keep reminding her not to strain and asking if she was all right. She sure didn’t look it! But she’d always come back with, “Em orait.” (I’m all right.) Getting her back into bed, she denied dizziness but stated that she felt quite nauseous. We tried to give a dose of oral Ondansetron but she vomited immediately and the pill was out. We replaced this with a sub-lingual dose that dissolved and, after a while, seemed to resolve the nausea. Her pulse was now 51-71 and her BP had dropped further to 119/85. Her O2sat was now 94% on room air.
Three hours after arriving, the patient’s heart rate was now down to 40-51, respiratory rate up to 36-40, BP down to 118/64, and O2sat at 94-96%. The moist cough continued. The patient continued to feel warm to the touch, likely due to the all the work her heart and lungs were doing. She denied being uncomfortable or in pain but cried when she saw her daughter return to her side.
The doctor continued to discuss with the patient and her daughter options. However, for a time we were afraid she may code on us! All of us were praying not! The best option for a positive outcome was for her to stay at the local hausik until a good surgeon in another hausik could do surgery to remove her thyroid. But the patient insisted that she would not go to a hospital. It had already been discussed with her family and she wanted to go back to her ples (place) and run out her time there at home. I could tell her daughter felt torn but this was an already made decision and all had agreed to abide by it.
By the fourth hour after arrival, the patient’s heart rate was 56, respiratory rate 28, blood pressure 98/64, and O2sat 93%. We discontinued her IV and gave her family a supply of Carbimazole and instructions on how she was to take it. She is to continue her Atenolol and Metoclopramide should she be nauseous. Still very leary of her decline but desiring to honor her wishes, we arranged a ride for them back to her daughter’s house in town where they will stay until arrangements can be made for her to be taken back home to her village.
At the news that she wouldn’t have to go the hausik her big smile broke out, she sat up, and spryly walked out to the car with a bounce in her step, much to the surprise of all of us who had been carefully watching her all day! She declared in no uncertain terms that she would be ok. She believed in Jesus and he had washed her sins away. He had promised her heaven and she would see us there! She walked holding my hand but not needing much balancing or support and then surprised me by spryly climbing between the front-leaning front seat and the door jam into the back seat of the vehicle!
This feisty, spry little woman beams joy in every smile! With a tight throat I told her I would see her later—if not here than there. And she pointed upwards with a big smile and said, “Yes, up there!” This may very well have been our last visit with one of my favorite patients but thank God it will not be the last time I see this sweet woman!