Imagine this patient presenting to your outpatient clinic.
She has DM, with weakness, DOE and chest tightness with exeriton. She was recently started on a statin obviously to improve her lipid status and protect her from future coronary events. My concerns/questions re: her hx, would be: DM well controlled in past? recent hgba1c?; has she been on a statin before?, h/o retinopathy/nephropathy?, h/o PVD, CVA or CAD? previous h/o chest pain/angina; smoker? Weight loss?
(i am ignoring hx given--so don't chastise me for re-asking questions please)
Immediate concerns/problem list:
1. like everyone before me is this unstable angina (change from baseline: chest tightness) or anginal equivalent. Does this warrant ED visit and admission? EKG, possible echo and eventually DSE vs treadmill stress. She will eventual need a cath
2. Rhabdo, due to myositis from statin
3. Liver disease/hepatitis, also from statin
4. low BG or high BG (with weakness episodes) her BG may be normal now but what is it when she has these episodes
5. Dyspnea
Anemia: 60 yo female, dyspneic with exertion, does she have occult bleeding?
CHF, story is not fleshed out enough to decide if this is heart failure (any h/o CAD, MI or ETOH)
COPD (maybe she is a smoker) (any reason for PFTs)
Pneumonia: early on: CXR would be nice
Hypothyroidism: lower on my list but possible. Weakness w/u includes TSH
Malignancy: possible lung, colon Ca; if new onset DM at age 60, (starts to raise red flag for pancreatic CA -- not something to screen for in every new diabetic, but keep in back of your mind); may cause DOE due to mets, anemia, effusion, etc....
6. Meds: insulin vs glucophage; beta blockers, etc. All can cause weakness/fatigue. Nausea/GI complaints secondary to statin is common
The other issue, does she need three sets of enzymes based on a 1 week h/o of this? I didn't start hours ago. It started a week ago. This is a fuzzy area. Everyone uses three sets and I don't agree with that. She at most needs 2 sets.
Someone called her elderly....I don't agree. She is older, but I certainly wouldn't call my dad, who is 60, elderly.
Finally, a lot of outpatient care and evaluation could be done prior to patient leaving. CXR (some places have them on site), labs (also on site), EKG (certainly every office should have one), Accucheck (also available on site). The only initial test I might want not quickly available might be an echo.
Some offices even have treadmill stress labs. I wouldn't stress her until I got my labs, CXR and EKG.
In my clinic, we send patients with c/o DOE (without CP mind you) for DSE all the time). It can be done.
What was done for the patient?
I would have to talk to her, know her pmh, and examine her before deciding on her dispo. Certainly, I would not send her to endo; Either ED or other are my initial choices left
