Primary care provider missed severe uremia
I work in a busy cardiology practice and see a plethora of patients daily. I had an extremely memorable experience with a patient that I had never previously met. The patient was a 72-year-old female whose chief complaint was an acute encounter of dizziness and lightheadedness. She had a history of vasovagal syncope, hypertension and CAD.
To prepare I usually like to review a patient's chart a little more thoroughly, but with an acute patient that is often not possible. Unfortunately, this patient also received most of her primary care at another facility to which we had limited record access. My very industrious nurse was able to get a copy of the patient's last lab from the other facility (performed three months prior to our appointment).
Of interest, the patient had been at her primary provider's office the day prior and was told to monitor her symptoms and see the cardiologist if they progressed. No diagnostic tests or labs were done at that time.
The patient's labs from three months prior were significant: potassium of 5.1, creatinine of 3.2, glomerular filtration rate of 17 and CO2 of 18. Kidney disease had not been mentioned in the cardiologist's last dictation, but sometimes only the cardiac-specific items are noted (though this was another reasons to have a thorough problem list).
The patient presented tachypneic, with a systolic BP of 70 and oxygen saturation of 79% on room air. She was ashen, and the fact that she could speak in full sentences still amazes me to this day. She denied shortness of breath or angina.
I immediately had the nurse obtain oxygen, and told her to contact the ED where we were transporting the patient to ask them to have intubation equipment available, as well as to page the nephrologist on call. I suspected the patient had developed severe uremia, and she was clearly acidotic. We had her in the ED within two minutes, she was immediately intubated and labs were drawn that showed a creatinine of 9, a potassium of 7 and a CO2 of 6.
To this day, I am amazed that this patient had compensated so well, and that her providers had not recognized her condition sooner. She was initiated on dialysis, and has done well.
The patient sent me a lovely plant to thank me that still adorns my windowsill, and she stopped by a few weeks ago to meet me for the first time. Not surprisingly, she did not remember me from our brief encounter. I have also had the good fortune of caring for her sisters who accompanied her that day. Both were very appreciative and expressed that they felt that provided excellent care.I am happy that I can provide such service to my community and hope that providers remember that a patient is not just the sum of their parts but much, much more; they deserve to be seen as such and should not be sent to specialists without considering the whole situation.