One of the great balancing acts in medical care is the family practitioner's decision about what to take on oneself and what to send to a specialist. This column has frequently shown the risks of the primary care physician doing too much, but sometimes, he or she may have the tools readily available to handle an urgent situation.
A 42-year-old woman with a history of smoking, hypertension, anxiety, and panic attacks had been the patient of Dr FP, a family practitioner, for 10 years. She was taking nifedipine, fluocinonide, dextroamphetamine-amphetamine, quetiapine, and vilazodone when she presented to Dr FP with complaints of dizziness, chest pain, and numbness in her feet over the previous 2 days. She reported that at one point she had been unable to stand and had called her mother for assistance while on the floor. She said that her heart rate at the time was in the 40s to 50s.
Dr FP noted blood pressure of 90/60 mm Hg (position not specified) and 84/56 mm Hg standing and a heart rate of 80 beats/min. Physical examination noted no cardiomegaly or thrills, a regular rate and rhythm, and no murmurs or gallops.
Dr FP discontinued the nifedipine out of concern for hypotension, but because the patient expressed a worry about a blood pressure spike, Dr FP prescribed hydrochlorothiazide and recommended a cardiologist referral if the patient experienced no improvement. Dr FP finished by ordering the patient's annual lab studies but did not perform electrocardiography (ECG), though she had the apparatus to do so.
Medscape Editor's Key Notes:
Consider administering an ECG when chest pain is a symptom.
If the patient declines your advice, document their refusal.
An active cardiologist referral rather than a wait-and-see approach is often important in cases of chest pain.
The patient returned 3 days later for follow-up and was still experiencing lightheadedness but no syncope. Examination showed a temperature of 101.9 °F; a heart rate of 80-90 beats/min; and blood pressure of 100/60 mm Hg (position not specified), 90/60 mm Hg sitting, and 82/52 mm Hg standing. Lab tests showed an elevated aspartate aminotransferase level and white blood cell count. Dr FP was not sure whether the patient was experiencing a viral or bacterial infection. She prescribed a Z-Pak (azithromycin) and recommended that the woman go to the emergency department for blood pressure support and further workup. The patient declined because of lack of insurance but promised to go if her symptoms worsened. A chest x-ray showed findings consistent with bronchitis with no evidence of pneumonia.
© 2021 Cooperative of American Physicians, Inc.
This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories.
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