The Not-So-Well Well Visit

Two well visits of note from yesterday:

1. 41 year old woman, new patient, for annual well woman exam. Says over the past month she is feeling tired, out of breath, heart racing at times (uh-oh). Eventually I get the key history that she has known mitral valve disease and was last seen by a cardiologist a year ago. She fails to mention that said cardiologist recommended surgery a year ago but the patient decided simply not following up any longer was a good alternative. She looks pale, thin (about 100 lbs), fatigued. I put my stethoscope on her chest and leave it there, and am amazed to watch it bounce up and down with such violence that I fear her heart is actually breaking through her ribs. Her murmur is impressive, but the precordial heave is even more so. I radio to my MA to get a pulse ox and an EKG (not the usual well woman visit requests). Her rhythm is atrial flutter with a rate of 120 bpm. Her oxygen saturation is normal, but she huffs and puffs trying to put on her clothes (Really? Out of breath from pulling on socks?!).

I tell her I am very worried about her and thinks she needs immediate evaluation at the ER. She is dubious:
Me: It looks like your heart has gotten a lot worse. I'm worried. You're so young, you have a lot to lose if you don't get this checked out.
Her: I'm not that young.

I bargain with her and settle on having her go directly to the echo lab in the hospital for an echocardiogram. Very shortly thereafter I get a call from the echo tech who says, "She has the largest left atrium I've ever seen in my career as a tech." She also has terrible pulmonary hypertension and severe regurgitaton of multiple valves. The tech is unable to evaluate her left lung (looking for fluid) because the heart is so large ("gigantic" per the echo report - an adjective I've never seen in an official echo report) it obscures the entire lung. We manage to convince her to go down to the ER for further eval.

Should I bill her office visit as preventive care only? Don't think so (but I did do the pap and hpv test, oh yes I did).

2. 11 year old male for well child check. Mom says "his hands shake all the time for about a month." The patient holds out his hands and sure enough he has a fine tremor, worse when he is reaching for things. Hmm... often familial, benign in adults (but in kids?!)... I start to explain this when mom says, "he also has been having a hard time speaking and he chokes on his food now for the past month." Ahhh! What happened to my well child check? You know, the ol', how's school? Here's a shot, see you in a year? We'll see what neuro has to say about his strange constellation of symptoms.

It was a busy one yesterday, to say the least.