Walking into the room, one could immediately noticed that Mr. Sutherland had severe dyspnea. He sat bolt upright (clearly a clue), but more remarkable was the look of apprehension on his face. One could imagine the fear that he had with every breath.
I went over to the bedside, shook his hand and introduced myself. The student had told me that he was having a COPD exacerbation. But he had not smoked more that 6 or 7 cigarettes a day. He had been drinking significantly over the last 3 months.
I asked him how he felt. He told me that he felt better than he did 2 days previously when he came to the ER.
Next I felt his scalene muscle and noted that with each breath it contracted markedly. Many years ago, one of my heroes – Dr. Orhan Muren – had taught me to assess accessory muscle use through this maneuver. I immediately understood how hard he had to work to breath, and I expressed it to the patient.
I asked him how long he had felt short of breath. First he said it had occurred over the past week. With more questioning, he told me that he had had to decrease activity for several months. I asked if he breathed better sitting up or lying down. He told me that he could not lie down and breath. He could hardly walk.
As I started my exam, I first felt for his PMI – it was in the 6th ICS, mid-clavicular line. He had marked tachycardia with a loud S3 gallop. I heard wet rales at his bases.
The diagnosis was not a mystery, but it had been missed. The ER physician had heard wheezing and ronchi and therefore assumed a COPD exacerbation. He had responded a bit to “breathing treatments.” The initial radiologist read his CXR as normal heart size, “non-cardiogenic pulmonary edema.” Everyone ignored his BNP of 13k.
We looked at his CXR. He is a small man, and at first glance his heart size does not appear large. But when you measure his CT ratio it exceeds 0.5. His Xray shows the classic signs of pulmonary edema.
We gave him 40 mg of IV furosemide.
I saw him 4 hours later, he remained tachycardic, but his breathing was significantly improved.
His echocardiogram confirmed his enlarged heart and LVEF of 25-30%.
The next day, he sat in bed looking comfortable. He no longer used accessory muscles.
I sat down and discussed his diagnosis, stressing the seriousness but explaining the promise of medical management.
While he expressed appropriate concern about his cardiac function.
As we left the room, he stopped us to thank us for our care. We had given him hope where there was none. We had relieved his sense of apprehension. We had provided care and cared about him. He expressed his thanks and almost had a tear of happiness in his eye.
As we left the room, I turned to the resident, intern and student and explained, “That is why I love being an internist.”
