So it's been awhile since I posted, and that's mostly because I don't really know what I want this blog to be in the future. Since I have started my first NP job, it's tempting to post about interesting cases I see there. But there are lots of other medical blogs that already do a similar thing very well. So, I think for the time being, I will continue to post very, very sporadically, more or less as I am inspired to write. The story below is pretty, ahem, inspirational.
I had an admission yesterday who completed of chest pain. Although he put it at about 6/10, he said it had been around for awhile, was more or less constant, and had no other cardiac symptoms. He had never had it worked up before and was able to converse with me at length without any outward signs of discomfort or anxiety. So, almost certainly not a heart attack, or even angina. What he did have was a number of respiratory symptoms, and a 20 year history of smoking half a pack a day. EKG normal. Signficant wheezing bilaterally in lower lobes. Physical exam otherwise normal. Blood drawn after.
I spoke with the patient about the fact his discomfort was likely due uncontrolled asthma or COPD. I said that he would need appropriate treatment, and might need further cardiac evaluation. I offered him the option of signing up for primary care at ARTC, but he declined, opting for a provider at North General Hospital. Fine. I wrote a referral to his future internist, explaining our findings, emphasized that to him that he should see his doctor soon, and referred hom for a chest x-ray.
This morning he is in my office for a dose eval. I asked if he had gotten his insurance sorted out and the CXR done. He told me he had instead gone to the emergency room. I asked why, he said "the pain in my chest". I reminded him he had had the pain yesterday and for months prior; what made him decide to go to the ER last night? He looked at me blankly before understanding, and stated halfheartedly, "It got worse." He was, however, pleased with his care. After all, they had done an EKG, bloodwork, and a chest x-ray. Then they had written him a referral for follow-up care.
Aaargh. I can't shake the feeling he went to the ER because I scared him by telling him something was wrong with him, but he didn't want to go through the administrative hassle of signing up for an actual primary care doctor, who almost certainly would have started him on appropriate care and referred him to a cardiologist. But now, he's been worked up twice in the same day for the same symptoms, and he still doesn't have an MD to prescribe what's needed for his asthma/COPD. So basically more dollars have been spent, and the overall result was worse.
American medicine is like 12% of GDP and yet our life expectancy is shorter. Stories like the above are why.
