Mr. R, my new 60-year-old patient, and I shared an alma mater, The Ohio State University. We immediately established a good rapport discussing the school's famous sports program. Mr. R's medical problems included adult-onset diabetes and coronary artery disease for which he had undergone bypass surgery 15 years before. Because he had no health insurance, he had not sought care for several years. He did take one aspirin a day, though, along with a combination of 40 different vitamins and supplements. His chief complaint was nighttime lower-chest pressure so severe that it prevented him from sleeping. Smaller meals seemed to have helped. I placed him on lansoprazole (Prevacid), ordered labs, and scheduled a follow-up appointment.
After five days on the prescribed regimen, Mr. R reported that his nocturnal chest pressure had improved, but it had not resolved. His blood sugar was >300 mg/dL and his hemoglobin A1c was 12%; he had microalbuminuria. I added metformin, metoclopramide (Reglan), and lisinopril to his medications and referred him for screening colonoscopy and possible esophagogastroduodenoscopy.
Before his next appointment, Mr. R was hospitalized out of the area for lower-chest and upper-abdominal pain. Gastroenterology and cardiology workups were negative except for the discovery of mild cardiomegaly. A combination of acetaminophen and hydrocodone (Lortab) as well as temazepam were added to his medications to help with sleep.
A few days after being discharged, a frustrated Mr. R appeared in the office to report that his nighttime discomfort was worse, and now shortness of breath accompanied it. Examination revealed an 18-lb weight gain and 3+ edema of the extremities. I stopped his metformin and began furosemide (Lasix), potassium, and insulin. Two days later and 14 lb lighter, he gratefully reported that his supine chest pressure and shortness of breath were gone and he could finally get a good night's sleep.
Unfortunately, despite continued fluid loss, Mr. R's recumbent chest pressure returned within three days. At this point, new cardiology and gastroenterology consults were obtained and a hepato-iminodiacetic acid (HIDA) scan was ordered to complete a thorough workup. Neither specialist could come up with a diagnosis, but the HIDA scan showed a decreased ejection consistent with chronic cholecystitis.
Following a cholecystectomy, Mr. R happily reported being symptom-free. Now we could devote more time to his other problems and, of course, to the all-important discussion of the next year's college football season.
Dr. Kagay is a family physician at Diagnostic Clinic in Largo, Fla.