By far one of our more challenging patients has been an\nelderly woman that has usually had different symptoms every time she came in.\nSerious ones! I began to tell her story in Big Hearts and Everyday Catch. Well,\nshe came in for another visit just 7 days after the last story ends. She had\ngained back 3kg of weight though she still looked quite gaunt. Her heart was in\nsinus rhythm but bradycardic (slow) at 55bpm. Her blood pressure held steady\nbut high at 158\/70. Concerned about what was going on with her heart we drew\nblood for labs. Her electrolytes were normal and her blood count fairly normal\n(hgb was barely low at 12.5) but her CKMB showed up as 19, CK low at 32, and\nLDH at 133. Still having cardiac issues but did not seem to be urgent. Heart\nfailure currently somewhat controlled but the weight gain could be retained\nwater. The doctor decreased her Atenolol dose and requested to see her back in\na week. <\/p>\n\n\n\n
Eight days later she returned with 2+ pitting edema and an\nadditional 2kg weight gain, increase respiratory rate and work of breathing.\nShe had been unable to keep any food down for the past 5 days and would vomit\nwhenever she tried to eat. Her heart rate was 60, BP 139\/72, and O2sat 95% on\nroom air. We again drew blood and checked labs. Her CKMB was now 21 and her LDH\n128. Not drastic but still a chance she could have had a mild MI (heart attack)\nthat was now resolving. Or could her congestive heart failure (CHF) be\nworsening? The doctor added 20mg of Lasix, 10mEq of Potassium chloride, and\nMetoclopramide as needed for nausea and vomiting. She was to continue at the\nsame dose of Atenolol and he wanted to see her back in another week. <\/p>\n\n\n\n
Ten days later she returned, always with the biggest\nbrightest smile for everyone and giggling easily, hugging and shaking hands\nwith all. She had gained an additional 5.5 kg of weight, had 2-3+ pitting edema\nin legs and feet. She says that it goes down when she takes Lasix but then\ncomes back shortly after. Per her daughter, the patient\u2019s tolerance for exercise\nis decreasing, now needing more help to get around and more breaks along the\nway. She is not eating much at all but is experiencing bloating. Her cough has\nincreased in frequency and it is now a very moist nonproductive cough. Uh-oh.\nNot a good sign at all. As we listened to her lungs she has diffuse rales\nthroughout. Chest x-ray showed a positive pleural effusion and her heart size\ncontinues to increase. We drew labs and sent some off to an Australian lab to\ncheck her thyroid hormone levels. There is a chance that the thyroid may be\ncontributing to these symptoms. The rest of her labs came back normal. The\ndoctor increased her Lasix and Potassium. She is to continue her Atenolol dose\nand come see us if things change. <\/p>\n\n\n\n
However, the doctor called the patient back in to the clinic\none month later, as soon as he saw her lab results\u2014TSH <0.8 (normally\n0.3-3.5), Free T4 47.7 (normally 9.0-19.0), and Free T3 >46.1 (normally\n2.6-6.0). This patient is in a hyperthyroid storm! The faulty heart valve\ndiscovered last July has likely helped along the CHF but the primary driver for\nher condition is a majorly overactive thyroid leading to what is known as a\nThyroid Storm! Upon entering, she had her usual huge grin and big hugs and\nspryly stepped up on the scale. She had lost 7kgs of weight. Good. Likely water\nweight decreased. However, once we had her seated and connected to a monitor,\nher heart rate registered as 121-182 and irregular, a new development and not a\ngood one! Her BP was 152\/86. With a stethoscope I confirmed the irregularity\nand asked another nurse to please bring the doctor right away and then help me\nget a 12-lead EKG and rhythm strip. The patient\u2019s temp was 38.6\u00b0C\nand she was quite warm to touch, a little diaphoretic (sweaty). She\ndemonstrated shortness of breath (SOB) and increased work of breathing at rest\nand felt more comfortable with the head of the bed up a bit rather than lying\nflat. The EKG showed atrial fibrillation (or A-Fib\u2026that is when the upper\nchambers of the heart beat super fast but the lower chambers respond only at\ntheir normal rate). We gave her 40mg Propranolol by mouth and started an IV and\ndrew blood work. Her potassium came back low at 3.0 (normally 3.5-5.0) so we\nstarted a slow NS IV drip with KCL. We also gave her Heparin subcutaneously and\nAspirin by mouth to help prevent a clot formation in her heart due to the\nA-fib. We also gave her Carbimazole to start decreasing the overactivity of the\nthyroid. She seemed to take all of this well. It was agreed that she would stay\nat the clinic until her heart rate was under better control. The Propanolol\nnormally takes a few days to take effect but we didn\u2019t feel comfortable sending\nher home in her present condition. <\/p>\n\n\n\n
This patient speaks a little Tok<\/em> Pigin<\/em> (the trade\nlanguage) but mostly in her tok<\/em> ples<\/em> (her village language) and had\ntrouble at times following what she was being told. There were more than a few\ngiggles on the part of the woman who was there with her as she tried to help\nask questions and answer them. This spunky lady has quickly become one of my\nfavorite patients to see in the clinic! <\/p>\n\n\n\n An hour after she\u2019d arrived, her heart rate was down to\n62-117, at times looking regular and other times irregular, still in A-fib. BP\nhad dropped as well to 114\/72 and O2sat stayed about 95% on room air. Her cough\ncontinued to be very frequent and moist. With her heart reaching the 60s and\nstaying there a time, we quickly rechecked a 12-lead EKG and rhythm strip. It\nstill showed A-fib, unchanged other than rate. We continued to monitor.<\/p>\n\n\n\n Within another 1-\u00bd hours she had a large emesis of yellow\nbile and was continent of loose stools. She kept laying forward in her own lap\nwhile on the toilet and I had to keep reminding her not to strain and asking if\nshe was all right. She sure didn\u2019t look it! But she\u2019d always come back with, \u201cEm orait.<\/em>\u201d (I\u2019m all right.) Getting her\nback into bed, she denied dizziness but stated that she felt quite nauseous. We\ntried to give a dose of oral Ondansetron but she vomited immediately and the\npill was out. We replaced this with a sub-lingual dose that dissolved and,\nafter a while, seemed to resolve the nausea. Her pulse was now 51-71 and her BP\nhad dropped further to 119\/85. Her O2sat was now 94% on room air. <\/p>\n\n\n\n Three hours after arriving, the patient\u2019s heart rate was now\ndown to 40-51, respiratory rate up to 36-40, BP down to 118\/64, and O2sat at\n94-96%. The moist cough continued. The patient continued to feel warm to the\ntouch, likely due to the all the work her heart and lungs were doing. She\ndenied being uncomfortable or in pain but cried when she saw her daughter\nreturn to her side.<\/p>\n\n\n\n The doctor continued to discuss with the patient and her\ndaughter options. However, for a time we were afraid she may code on us! All of\nus were praying not! The best option for\na positive outcome was for her to stay at the local hausik<\/em> until a good surgeon in another hausik<\/em> could do surgery to remove her thyroid. But the patient\ninsisted that she would not go to a hospital. It had already been discussed\nwith her family and she wanted to go back to her ples<\/em> (place) and run out her time there at home. I could tell her\ndaughter felt torn but this was an already made decision and all had agreed to\nabide by it. <\/p>\n\n\n\n By the fourth hour after arrival, the patient\u2019s heart rate\nwas 56, respiratory rate 28, blood pressure 98\/64, and O2sat 93%. We\ndiscontinued her IV and gave her family a supply of Carbimazole and\ninstructions on how she was to take it. She is to continue her Atenolol and\nMetoclopramide should she be nauseous. Still very leary of her decline but\ndesiring to honor her wishes, we arranged a ride for them back to her daughter\u2019s\nhouse in town where they will stay until arrangements can be made for her to be\ntaken back home to her village. <\/p>\n\n\n\n At the news that she wouldn\u2019t have to go the hausik<\/em> her big smile broke out, she sat\nup, and spryly walked out to the car with a bounce in her step, much to the\nsurprise of all of us who had been carefully watching her all day! She declared\nin no uncertain terms that she would be ok. She believed in Jesus and he had\nwashed her sins away. He had promised her heaven and she would see us there! She\nwalked holding my hand but not needing much balancing or support and then\nsurprised me by spryly climbing between the front-leaning front seat and the\ndoor jam into the back seat of the vehicle! <\/p>\n\n\n\n This feisty, spry little woman beams joy in every smile! With\na tight throat I told her I would see her later\u2014if not here than there. And she\npointed upwards with a big smile and said, \u201cYes, up there!\u201d This may very well\nhave been our last visit with one of my favorite patients but thank God it will\nnot be the last time I see this sweet woman! <\/p>\n","protected":false},"excerpt":{"rendered":" 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 […]<\/p>\n","protected":false},"author":1120,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[1],"tags":[],"class_list":{"0":"post-1075","1":"post","2":"type-post","3":"status-publish","4":"format-standard","6":"category-uncategorized","7":"entry"},"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/blogs.ethnos360.org\/tobi-magill\/wp-json\/wp\/v2\/posts\/1075","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.ethnos360.org\/tobi-magill\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.ethnos360.org\/tobi-magill\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.ethnos360.org\/tobi-magill\/wp-json\/wp\/v2\/users\/1120"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.ethnos360.org\/tobi-magill\/wp-json\/wp\/v2\/comments?post=1075"}],"version-history":[{"count":0,"href":"https:\/\/blogs.ethnos360.org\/tobi-magill\/wp-json\/wp\/v2\/posts\/1075\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.ethnos360.org\/tobi-magill\/wp-json\/wp\/v2\/media?parent=1075"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.ethnos360.org\/tobi-magill\/wp-json\/wp\/v2\/categories?post=1075"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.ethnos360.org\/tobi-magill\/wp-json\/wp\/v2\/tags?post=1075"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}