A patient comes in complaining of right foot pain -- and then it escalates!
Watch the video to see what happens.
You never know what you might find, so don't get pigeoned-holed into a diagnosis. It's important to take the whole person into consideration.
Let me know what you think about this unique story and if you think most doctors would catch this condition.
Bits of information were changed to maintain the patient's privacy.
Read the transcript below:
Hey, guys. Welcome to another episode of the Wednesday Checkup. Today, I want to tell you about a really interesting patient encounter I had just the other day, and then we're going to follow up that story with one of my favorite segments, Mail Time. You ready?
My nurse rooms the patient, takes all the vitals, brings all the information -- including the chief complaint to me -- and 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 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 taking a lot of medications for them -- hypothyroid, osteoporosis, type 2 diabetes, high cholesterol, and 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 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. 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 is 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. There were all these sorts of explanations he had in his mind for why that was happening. I listened to the patient's lungs. It's 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. The 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 is racing or beating outside of their chest. That's a very common way to explain it. 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 [atrial fibrillation] kicking in. But it went away, so I assumed nothing of it." I said, "Okay, let me do something. Let me get an EKG just to see how your heart is doing, how fast is it beating, and confirm that this is, in fact, Afib. Then we'll move on from there." 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. 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 the 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 is 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. ST depressions, specifically on an EKG, signify that the heart isn't getting enough blood and it's suffering. It's essentially being choked out. We call this a type 2 MI, which is 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. 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 going to 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. Once that started happening, they had a cardiovascular doctor see the patient and decide what the plan was going to be moving forward. 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 to 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 into 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 is improving. 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 going to fair and the better the person sitting in front of you is going to fair.
, (better known on social media as "Doctor Mike") is a board-certified family medicine physician at the Atlantic Health System's Overlook Medical Center in Summit, New Jersey. His educates over 3 million subscribers with two weekly shows covering everything from trending medical stories and health myths to reaction videos critiquing popular medical TV dramas. His goal is to expose medical misinformation and increase health literacy for a previously untapped audience of young adults.