Listening to our patients

Around 30 years ago, LRZ taught me a most important lesson.  LRZ, one of my most fondly remembered patients, was a classic blue collar guy.  He had a wonderful gregarious personality.  He had significant systolic dysfunction, yet still worked hard for the city.  Amongst other things he did, he shoveled the salt into trucks on snow and ice days.  He functioned well most days. One day he came to see me.  In those days, prior to ACE inhibitors or the use of beta blockers, we focused on digoxin and diuretics.  As I picked up his chart I noted that he had gained 3 pounds.  From past experience, I knew that he would soon have progressive symptoms. I examined him and noted bibasilar rales.  This occurred on a Monday, and I had more opportunities to see him that week.  He told me that his fusosemide (Lasix) was not working as well as usual.  So I assumed diuretic resistance, and planned to give him a dose of metolazone (5mg) in addition to the furosemide.  As we went over the plan, he paid attention.  I planned to bring him back in two days to check his weight, his lungs and his potassium.  (For current trainees, in the absence of ACE inhibitors or ARBs, we saw much more hypokalemia, and the combination of a loop diuretic and thiazide both produced massive diuresis and significant hypokalemia – very dangerous given the doses of digoxin we used in those days). After laying out the plan, and making certain that LRZ understood, I got ready to leave the room.  As I r...
Source: DB's Medical Rants - Category: Internal Medicine Authors: Tags: Medical Rants Source Type: blogs