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 furosemide (Lasix) was not working as well as usual. So I assumed diuretic resistance, and planned to give him a dose of metolazone (5 mg) 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 reached for the door handle, LRZ stopped me. “Doc, thanks for everything, but I came in because of my right shoulder pain. I hurt it shoveling.”
I examined him, and made a clinical diagnosis of tendonitis. Then I asked the most important question. What are you taking for your shoulder pain. LRZ responded, “Aleve.”
And then I understood. Diuretic Resistance and Strategies to Overcome Resistance in Patients With Congestive Heart Failure:
Drug-drug interactions have been associated with diuretic failure and, ultimately, resistance. Non-steroidal anti-inflammatory agents (NSAIDs) may alter renal hemodynamics by decreasing renal blood flow. In severe heart failure, prostaglandins play an important role in renal perfusion. Prostaglandins promote sodium and water excretion, and prostaglandin inhibition with aspirin or other NSAIDs has been shown to attenuate diuretic efficacy. Hall noted an impressive reduction in diuretic requirements when daily administration of as small a dose as 100 mg of aspirin was stopped.
So we stopped the Aleve and helped him return to his desired weight.
LRZ reinforced the importance of listening to the patient before we develop our plans. How often do we learn more from listening to our patients than barreling forward with our agenda? Listening takes a bit of time, but it really saves time. As a physician, we work to help our patients. Therefore we must understand their concerns, their issues, and their plans.
LRZ taught me to listen to the patient before developing our plan and before pontificating. LRZ helped me become more patient centered. Rest in peace LRZ.
Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.
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