 Provided by Clinician 1
I had an opportunity to meet a new female patient this week. In her early 50’s, she presented with a wary demeanor, rather hesitant overall. After my initial introduction and explanation about our practice philosophy and protocols, I discovered why she looked like a skeptic. It had nothing to do with seeing a Nurse Practitioner. Rather, it was built on frustration after suffering health issues...for two and a half years...and no apparent answer in sight.
When I asked her why she had come to our practice, she told me that she was sick and tired of feeling awful...and getting “the run-around.” After seeing her PCP for years, and a multiple of specialists, she STILL felt awful. No one could help her or explain what was wrong. She started her story in the present, with what was going on NOW.
I gently stopped her. Please, I asked her; start at the beginning. She was incredulous when I told her this. “You gotta be kidding me!” was her response. Her symptoms had started in the spring of 2008, and she was surprised that I wanted to hear the whole story. I felt that it may give me a clue to her issues. Her chief compliant was a “choking sensation with mucous” and a cough...that ONLY occurred when she was lying down. She also has had constipation, but her PCP told her that she could not have a colonoscopy, as her insurance would not cover this. Oh, and she has had a multitude of stressors in her life as well.
Fast forward to November, 2010, and she had what I would call the “million-dollar work-up” in the past 2 ½ years. Her PCP consulted cardiology, ENT, gastroenterology, and pulmonary specialists. Her tests included a CXR, nuclear stress test, echocardiogram, PFTs, CT scans of the chest, abdomen, and pelvis, abdominal ultrasound, and an EGD in April, 2008. All of the tests were normal. Of note, the GI specialist recommended that she use a PPI and Miralax, but she never took these medications, as she usually “likes to avoid pills.” She did not understand the rationale behind the meds. Her PCP suggested months prior that it was anxiety causing her symptoms, but the Lexapro did nothing after four months, so she stopped it.
As she told me this story, my immediate thought was reflux. However, I forced myself to continue to listen. The more she told me, the more astounded I was that all of this had transpired, without anyone going back to reinforce her trialing an H2 blocker or PPI. Especially since her symptoms ONLY occurred with lying down. No smoking or asthma history. Hmmm…
After she was finished, I did my exam...tenderness in the epigastric area to palpation. I reviewed all of the test results online via our computer system, which links to the hospital computer. After verifying that these results were indeed normal, I discussed my thoughts with her.
“But I don’t have heartburn,” was her first comment, when I mentioned GERD as a possibility.
I explained how reflux can cause symptoms as she has, without the “typical” heartburn. We discussed usual food triggers, elevating the HOB, avoiding eating later in the evening, etc. I prescribed omeprazole, and we scheduled her a follow-up visit to re-evaluate her in a few weeks. She will call me sooner if there is no change, and I will refer her back to GI. I also advised her that constipation DOES qualify for a reason for a colonoscopy, although it is not a “screening” exam. And yes, please take that Miralax.
I think this points out our strengths as NP and PA providers...we make that effort to listen to our patients...to get the “whole” story. Yes, I had the advantage of the patient having had the “million dollar work-up” before she saw me. However, I would have done the same thing even had she not had it. And so would most of us, I suspect.
The lost art of listening is something that we need to focus on...and in these next few years of insurance cut-backs, we will need to rely on this even more.
Kim Spering is a family nurse practitioner who currently works at Brndjar Medical Associates, P.C., a family practice in Emmaus, PA. Her past experience includes the fields of medical/surgical ICU, open heart/trauma ICU, labor and delivery, nursing education, nursing supervision, and as a nurse practitioner in both family practice and OB/GYN settings. She currently serves as a NP preceptor for her graduate school alma mater, DeSales University, as well as for local baccalaureate programs. She is passionate about patient education and helping patients understand that they are ultimately responsible for their own health. She also firmly believes that the public needs to be educated on the value of NPs and PAs in meeting the health care needs of the next decade and beyond. In her free time, Kim enjoys family vacations with her optometrist husband, Mark, and her two sons, Matthew and Connor.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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