Intuition saved this patient from a potentially fatal diagnosis

I was working in a rural health clinic when I went into to see a new patient.  Amy was 18 years old, with her 6 day old newborn son by her side.

I introduced myself and then asked, “what brings you into the clinic?”

Amy responded, “Shortly after giving birth, I started having problems with shortness of breath, ankle swelling, and high blood pressure.  I told the OB residents and they brushed it off, said it would go away.”

“So what happened after you went home?”

“My shortness of breath, ankle swelling got worse.  I started having fevers, so two days ago I went to the hospital ER next door,  and they said I had a UTI and put me on antibiotics.  But I know that’s not what’s wrong, it’s something else.  That’s why I’m here.”

“Okay.”

With that, I proceeded with the needed work-up.  I did her physical exam and found a S3 gallop on her cardiac exam.  She had pitting ankle edema, as well as the elevated blood pressure.  In addition, she was unable to lay down to breath.   Instead she needed to have her  head elevated.

I sent her to the lab to have a urinalysis done to follow up on her UTI.  With that  I ran out the back of the clinic and went next door to my supervising physician’s office, where I presented Amy to him.

When I finished he said, “The symptoms Amy is having is typical post-partum.  Just give her metoprolol for her blood pressure and have her come back in two days for follow-up to make sure the med is working.”

My intuition told me this wasn’t the answer, but I didn’t know what else to do.  Amy went home on metoprolol, scheduled to come back in two days.

I couldn’t get Amy off my mind.  I went to bed thinking about her.  The following morning I awoke with a start, all of the sudden I knew what was wrong, she had the same disease I had seen in another patient several years before.  I dressed hurriedly, then literally ran to the medical library to find articles on diagnosing post-partum cardiomyopathy (PPCM).

I was ready the next morning for Amy.  By now she was coughing up blood.  I sent her for an EKG and CXR.  Now, in addition she had fine crackles heard over her lung fields.  I had the MA put her on 4 liters of oxygen and get a pulse oximetry.  I went to go call the admitting cardiologist and after presenting Amy to him, he literally yelled over the phone at me to get her to him ASAP, for yes indeed she had PPCM.

Amy’s case taught me a lot.  I learned to listen to my intuition and when it said something wasn’t right, to listen.  I learned it was important to make my own diagnostic assessment and not assume other physicians were always right in theirs.

Sharon Bahrych is a physician assistant who blogs at A PA View on Medicine.

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