On the list of things I expected to hear today, this was not near the top
I'm was a little upset this evening, but I'm getting more comfortable now.
I called my GI doc three days ago to discuss my ongoing issues, and I was able to get an appointment for this afternoon(!). The nurse that did the preliminary vitals and whatnot stuff was unfamiliar to me. She told me that the GI folks were borrowing her for the day from Cardiology downstairs. For some reason she decided to listen to my heart… and she took a really long time doing so. I don't remember anyone listening to my heart before except at my PCP's, and never for so long.
"Hmm," she said.
"'Hmm'? What does 'hmm' mean?" I asked.
"I think you have a heart murmur… has anyone ever told you this before?"
"Uh, no. No one's told me that before."
"I see… let me listen again."
Another long pause while she listens.
"Yep, sounds like you have a murmur. Let me tell [Dr GI] so he can have a listen."
We then go on to have a five minute discussion about drugs, psychopharmacology, clinical pharmacy, and people with entitlement issues. (WTF)
My doc comes in, says hello, we talk about a great many things like we always do (last time we talked about the ins and outs of the laws governing anesthesia and CRNAs in the state of Massachusetts and this time we talked about Thanksgiving, travel, and energy efficiency and how it relates to electrical engineering. I love my GI doc — he's great.)
I was substantially less freaked out at this point, and we both almost forgot the murmur. He listens with me sitting up and lying down. He confirms it, suspects PVCs — something I've suspected I've had for about four years now — and we talk cardiologists. Turns out, one of the guys downstairs is an arrhythmia specialist, and does a lot of work with people my age.
–
I've been having mental battles with myself over the last couple of weeks whether I'm merely a hypochondriac, or if there's a real problem with whatever body part is letting me know it's there. I don't like to diagnose myself; I don't like to be one of those people. But I know that 1) I don't like going to the doctor every other week 2) I don't like taking pills and 3) I do my damnest not to be one of the people who taxes the system. I think that sort of rules out hypochondriasis.
Dropping a diagnosis on someone can be very disconcerting, even something relatively benign (most likely) like arrhythmia. Intellectually, I know that heart arrhythmia aren't a huge deal. I know millions of people have some kind of arrhythmia. I also know that most people have PVCs at some point during their life, and that rare is the person who has never had a skipped or extra beat. I have suspected that I have had some kind of heart trouble since the first time I walked up some stairs and I couldn't get my heart rate to drop for about five minutes.
I thought it was just the amphetamines I was taking at the time for ADHD. I'm certain those didn't help.
Since then, I've had four EKGs, and had my heart listened to by four doctors and countless nurses. They've all told me that I'm fine; there's nothing wrong. I heard it so many times, I believed it. I chalked it up to mere anxiety.
I'd just like to tell the world that I'm fucking tired of people ruling out something *actually* being wrong simply because I'm young. Delve deeper. Refer, if you must. Sitting here in my chair, sipping my decaf Columbian, this revelation explains a few things that I noticed were different about myself since since first grade.
I was always a pretty strong long-distance runner, but I suspect that's simply because walking was never (mentally) an option. I DID notice (and other parents noticed) that it took me longer to recover than the other kids. Where I might run a mile in 7 minutes or so, it would take me 45 minutes to an hour to get my breathing under control where other kids would be fine in 10 or 15 minutes.
Being in first grade, I thought nothing of it the first time someone said something to me about it. My chronic ear infections and multiple cases of severe poison ivy tended to be more pressing.
In junior high and early high school, I had a paper route, and despite biking 5-10 miles every day loaded down with newspapers, my CV endurance never really got beyond a certain point. When I played lacrosse in high school, my heart felt like it was going to explode pretty regularly. Moreso than the other kids.
More recently, while at the gym, I've hated cardio. There are days where I can run for 45 minutes to an hour and be fine, except for the very long recovery time afterwards. Other days, as soon as I move past a walk, I can feel my heart skipping beats. If I continue on, I get lightheaded and have to sit down. (Otherwise I'll fall down.) The more regular I am with cardio, the worse this problem is. It doesn't get better, it gets worse. Oh, and there's also the fact that about 10% of the time that I take a deep breath, my heart skips. (This is why deep breathing doesn't work for me when it comes to managing panic attacks.)
Of course, there's nothing wrong with me. I'm too young to have anything wrong with me. 19? 21? 25? Fuck it, it's all in your head. Maybe these R tards should read Groopman's book and try to take some of the principles to heart.
So while I was a little upset today at being informed that I have a heart murmur, I am somewhat comforted to know that I'm not mentally defective (at least not in that way 
), and that perhaps I have an answer. At last. Yes, I know murmurs come and go. They're not always present while the provider is listening. But a Holter monitor was never discussed. Maybe I should have been more pushy. But like I said, I didn't want to be one of those people.
–
Back to diagnosis dropping before I close. Knowing something in your mind and reconciling it with the emotional reaction you have to this input are two completely different animals. In fact, logical reconciliation doesn't come until later, if at all.
I have been guilty of being somewhat dismissive when someone tells me something that's obviously bothering them. If I know it's trivial, or a problem that's easily managed, you tend to not think of it as a terribly big deal. Familiarity with and exposure to a disease state causes a recalibration of Normal. Perhaps even indifference.
But nothing is trivial, even if it's not serious or life-threatening. Not to the person receiving the news. Nothing. (Unless they're drugged out of their mind, like I was when they said "Hey dude you have Crohn's." I just didn't give a fuck at that point.)
Oh, and what takes the cake is that when I got home from work tonight, and informed my family of this revelation, my mom laughs and says "Oh yeah, I have a murmur, too." and my grandmother pipes up and tells me she's got one, too. What the fuck, people. TELL ME THESE THINGS so when I'm asked if there's any history of illness in my family I can give the correct answer. I know my grandfather died of a heart attack, but I always thought he was an isolated case and it was because he was a lifelong smoker and alcoholic. :rolleyes: But no, apparently most of my grandmother's brothers and sisters and my own aunts and uncles have murmurs, too.
The mind boggles. Apparently this information is trivial.
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Murmurs and arrhythmias are apples and oranges. The only thing they have in common is that they involve the heart.
Here's how I talk about it to patients:
The heart has three separate systems: mechanical (valves which can leak or not open wide enough); plumbing (coronary arteries, blockages of which cause MIs); and electrical, which is the source of arrhythmias. Murmurs are mechanical issues.
Your murmur is probably innocent, but if a good cardiologist can't tell for sure by listening, then the test you need is an echocardiogram.
That exercise intolerance history and arrhythmia stuff is a little more concerning. I just had a relatively young patient who needed a pacemaker for chronotropic incompetence: her heart couldn't speed up to meet myocardial demand when she exercised. The money test there is a treadmill stress test, though they're looking more at rate and rhythm with exertion than for ischemic changes.
Good luck.
Comment by #1 Dinosaur — November 21, 2007 @ 11:39 pm
Thanks for the explanation. I probably would have paid closer attention in physio and patho had I known I would have had this problem. Cardio was so boring back then.
Now I want to know everything about everything. How things have changed in 2.5 years.
Comment by RJS — November 22, 2007 @ 12:02 am
Now that I think about it, the nurse said "murmur" and the doctor said extra heartbeats. Probably PVCs.
Is "murmur" used in a more colloquial sense to mean "sound abnormality"? Regardless, that'll have to be sorted out, I expect.
Comment by RJS — November 22, 2007 @ 12:07 am
Nope: a murmur is a murmur. Other "sound abnormalities" are called "clicks" and "snaps" and "venous hums."
"Extra heartbeats" have the same sound qualities as "regular" ones. If a valve is leaking, it doesn't matter where the electric impulse that stimulated the beat originated (sinus node vs. elsewhere); it'll still leak — and give off the same murmur — with each beat.
Comment by #1 Dinosaur — November 22, 2007 @ 12:22 am
A word with a specific meaning, then. Thanks.
I wonder what my problem will end up being. :rolleyes:
Comment by RJS — November 22, 2007 @ 12:42 am
Please get checked out for GERD. PVCs caused problems for my husband and his three siblings (all in their 40's) and it turned out to be GERD.
Once you're on Prilosec you'll be AMAZED at the number of symptoms that go away.
That night-time or early-AM asthma? GERD! Google around and check it out…
Do you need to get actually scoped for GERD? That's up for debate, most people just get vast symptomatic improvement with the PPI treatment, but GI docs *LOVE* to do upper GI scoping. It's apparently a very profitable procedure (great reimbursement), relatively benign and low-risk – but dang it's uncomfortable.
I'll let you & your GI doc decide. Ask him if he's funding a new wing in his clinic or remodeling his house when he whole-heartedly suggests getting an upper GI….
Comment by DP — November 22, 2007 @ 11:23 am
I have Crohn's disease localized (right now) to my terminal ileum. (End of my small intestine just before the colon.) Crohn's can flare anywhere from the mouth to the anus, and because this flare felt different than the others, it seemed prudent to check my upper GI tract, particularly because I've been having some reflux and slower gastric emptying than normal.
I will be completely unconscious during the procedure. I could probably write a haiku about propofol. …Maybe I will.
My GI doc is the bomb. He lets me decide what I want to do (or not do) with his guidance. I'd hang out with him outside work he's just that cool.
Comment by RJS — November 22, 2007 @ 2:19 pm
[...] This week's topic is panic disorder and relapse in patients with and without a history of substance abuse. Fun topic, really, and one close to my heart. [...]
Pingback by On panic disorder and benzodiazepine use :: OnThePharm — April 1, 2008 @ 10:27 pm