Case Study 1

Six weeks ago, a 55 year-old white male had surgery for cervical spondylolysis. Since discharge from the hospital, he has started feeling intermittently lightheaded. Who should he see? He describes multiple episodes of lightheadedness since his hospital discharge. These have occurred with standing, and improved with bending forward. Separately, he has had three episodes of chest pain and paliptations. The chest pains have occurred while sitting, lasted about five minutes, and improved slightly with combivent. During hospitalization, the patient experienced several complications. These included, successively, cervical myelopathy, ulcerative esophagitis, and urinary retention. He received, respectively, prednisone, omeprazole, and tamsulosin. During his final week in-hospital, he received mirtazepine for depression. Discharge medications included those mentioned, oxycodone, cyclobenzaprine, iron and stool softeners. He had underlying COPD before admission, and during his hospitalization an initial workup was begun for lung transoplantation. On discharge, he remained on combivent, advair, and bupropion. The latter had assisted him with tobacco cessation prior to admission. Who should this man see for his new symptoms? Should he see Neurosurgery? Should he call Gastroenterology, or Urology, each of which had started new medications? Should he try to see the Physical Medicine and Rehabilitation specialist who had cared for him during the last week of his stay? Should he see Cardiologist? Pulmonology? Should he go to the Emergency Department? How should such a patient decide? The patient decided to see his primary care doctor, a family physician. On examination, he was not orthostatic. He had lost significant weight since hospitalization. His respiratory status was stable. An EKG in clinic was normal. The differential diagnosis for his lightheadedness, chest pain, and palpitations included cardiac and pulmonary etiologies, medication side effects, infection, and other possibilities. The primary care physician considered that tamsulosin, started by Urology, can lower blood pressure. Weight loss and tobacco cessation can add to hypotension. Further, bupropion can cause cardiac arrhythmias. The patient required maintenance of tobacco cessation for any chance at a lung transplant. He was already taking one antidepressant. Tamsulosin was reduced from twice to once daily. Bupropion was discontinued, and the patient was counseled again in depth regarding tobacco cessation. Mirtazepine was continued as much for its antidepressant effect as for its side effect of weight gain. The patient's lightheadedness, chest pain, and palpitations resolved. Since urinary retention did not return, tamsulosin was soon discontinued completely. While the patient had no objective evidence of arrhythmia, and no holter monitor or other arrhythmia study was performed, his palpitations did not return. The patient did backslide into smoking once, by his own admission largely to delay his chances for pulmonary transplant, about which he was very nervous. This anxiety was addressed in follow-up visits, and soon the patient remained tobacco-free. Q: Please discuss the relative benefits and limitations of primary care and specialist approaches to medicine in such a case, including their impact upon the patient.