My New Patient Narrative, Part I

Last year, in our Medicine in Society course, we had to write our own "patient narrative."  As future physicians, it is easy to forget what it means to be sick, even though we will see sick people every single day.  We tend to forget what it means to be sick ourselves, since we're supposed to be the healthy ones, caring for those in need.  So, each of us discussed a time in our lives when we were ill, and what it was like to be a patient, how we felt, etc.  (See September 2009 post: The Story Behind the Story).  I argued that I have never really been "ill" although I've been sick quite frequently.  To be "ill" implies something much more than a common cold or the seasonal flu. Illness is more serious, and it has just as much to do with access to health insurance and socioeconomic status as severity of disease.  I argued that even in my sickest, I have never been ill.  I still have yet to be ill; but if I were writing that assignment today, I would use a different story.

Before I started school, I was told there are two types of med students: those who think they have every disease they learn about, and those who believe they are invincible.  I now know that I fall into the former category.  Copious purulent sputum?  That used to be a run-of-the-mill sinus infection for me, but now it's bronchiectasis from primary ciliary dyskinesia.  Headache and disorientation in the morning?  Not from drinking.  It's probably encephalopathy due to acute liver failure.  So it should be no surprise that when I had my blood pressure last checked, the high reading made me think I was 3 months away from my first transient ischemic attack.

On the offhand chance it was worth checking out, I mentioned this to my friend Klara Klein during this year's Cardiology block.  Klara is my resident cardiologist, since her dad is a real one here at UNC.  She ran it by her pops, and the next thing I knew I was getting my first ultrasound.  Now it is important to note that there were a couple steps in between.  I did see my primary care physician, and we did check my blood pressure consistently over a 1 month period (and it was consistently high).  I never had a reading under 135/85, and most were in the 140/90 range.  This is unusual in a slender, former athlete, who eats fairly healthy and is sodium conscious.  So the recommendation was to go on a low dose diuretic.  It's dirt cheap and would lower my pressure about 10-15 points, about what I need.  The only downside would be that I would have to pee a bit more in the mornings. I did want a second opinion, though, if I was going to be on a medication for the rest of my life.

On principle, I would like to be taking as few medications as possible, i.e. zero.  With the exception of the weekend brews, I want to keep my body as drug free as possible.  But I've also held in my hand the aorta of a hypertensive 40 year old man who died of an aortic aneurysm.  Hypertension is a silent killer.  It may take decades of high blood pressure to kill you, but it will do just that.  It was the experience of actually feeling the rough atherosclerotic plaque, and comparing it to the smooth, normal aorta, that pushed me over the line. If I need to do something about my health, I might as well start now.

The echo was meant to see if I had any congenital abnormalities that would cause my blood pressure to be abnormally high.  It was not meant to see what it did...  that I have a large right heart.  Now initially I thought that was a good thing (doesn't it just mean I have more room for love?!?), but I have taken enough cardio to know that this is abnormal.  There are numerous etiologies to "big right heart" syndrome, such as pulmonary hypertension or atrial septal defect (ASD), or it may be just idiopathic, and that's just who I am.  But it's important to rule out these pathologies first.  So, next thing I knew, I had a "bubble study," where bubbles of normal saline were shot into my right arm to see whether any bubbles crossed into my left atria from the right (it's a very cool study; you can see your heart and the bubbles in real time on echo!).  If they did, that would show that there's a hole between the two atria (ASD), and that hole could be closed with surgery.  That test was negative, and an MRI was indicated to r/o (rule out) other etiologies.

I have simplified the tests, appointments, and discussions because they have all gone by very quickly.  But I won't gloss over the fact that I have been a bit apprehensive during this entire process (which can't help my blood pressure).  My father has made fun of me because many of my stories have become more morbid over the past year and a half.  If all you learn about are things that go wrong, then the cup is half empty.  We have learned about some serious conditions that are associated with right atrial and ventricular hypertrophy, and frankly it's a bit unnerving.  Whatever the mechanism, this could have gone unnoticed for decades.  It is scary to think that I've had no control over whatever is going on.

If you haven't experienced an MRI, it's best to stay away.  Frankly, I think every med student should have to have one, just so we know what we're putting our patients through.  I sat in that tiny little tube for an hour and a half with loud beeping and banging going on constantly.  It was uncomfortable, but I know there are people who have to have MRIs much more often than I do (my mother for one).  But for me, to what end?

A cardiac catherization has been thrown around as an idea to find out what the pressures are in my heart, but since we probably won't do anything about it yet, there's no reason to rush.  So, for now we monitor.  The MRI looked clean (except for my monstrous coronary arteries which received "highest honors" for their impressive size).  It is probably nothing.  Most likely, this is just who I am.  I have a weirdly large right side of my heart.  It will probably never affect me, and I will live my life like nothing happened.  Every few years I will have an echo to keep an eye on it.  It certainly didn't affect me as a swimmer, and if I want to go out and run 10 miles tomorrow, I know that I can still do that.  However, deep down I was hoping they would find something.  Something fixable.  That way I would know.  If you know what's going on, you have some control over the situation.  The ambiguity is disheartening (pun intended).  In all seriousness though, the word "idiopathic" has suddenly become personal.