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Dr. McLaughlin:
Hello, I'm Val McLaughlin from the University of Michigan. And thank you for joining me on this case presentation where we're going to talk a little bit about diagnosis and risk assessment in patient populations that are perhaps a bit underserved.
And this is a patient who is 54, who's had about a 6-month history of progressive dyspnea. She has a history of hypertension and obesity, and she saw her primary care provider. Now she lives in a rural area, there aren't a ton of medical resources, but she saw the primary care provider and explained the shortness of breath. And, you know, I think he did a really great evaluation, history, physical, and ordered some basic work with up including labs, EKG, chest x-ray, and an echo. And the echo showed mild right ventricular enlargement and dysfunction, moderate tricuspid regurgitation, and an estimated RVSP of 52 millimeters of mercury.
And, you know, I think it's great that a provider recognizes their limits, concerned that this might be something more serious, and he said to this patient that they need to come down to Ann Arbor to be seen in the PH specialty center there. Now, Michigan, like many other areas of the country, is a state that has some more densely populated areas and lots of medical resources, and other areas that really are less densely populated and don't have as many resources. But he made the referral that, we made an appointment, she didn't show up for the appointment, we rescheduled it, she didn't show up. So she's now no-showed twice. And so our PH nurse reached out to her to try to understand what the barriers were and really learned that she has transportation challenges. She, you know, lives a good solid 2 hours away from us, and really struggled to get the resources to come and actually be seen in the center.
So, you know, not that there were great things about the pandemic, but one of the things we learned about the pandemic is how to use virtual care. And we actually reached out to her and said, ‘Let's try to do this as a video visit so that we can get a sense of what's going on,’ explain the evaluation to her, determine what tests need to be done. So the initial visit I had with her was via a video visit, and we had some of the test results that were done locally. You know, I certainly did have a concern that she had pulmonary hypertension. And we talked about that diagnosis and the further testing and about the challenges that she had. It was very difficult for her to get down to Ann Arbor. So we arranged for a lot of things to be done locally: labs, PFTs, VQ, we arranged to have those done locally. But the right heart cath is something that, as we all know, is really important for the diagnosis of pulmonary hypertension, and needs to be very methodical and well done. So what we did is, you know, we got all the other testing locally got those results, and then scheduled all the remaining testing that she needed, including the right heart catheterization, in one visit, at which time she also saw us in person so that we can meet her in person, examine her, our nurse could spend some time educating her. We also arranged for social work to see her then, so we could try to start addressing some of the barriers that she had in terms of transportation.
So we did - we completed the evaluation and the risk assessment, and she fell into the intermediate-risk category. Her hemodynamics did not push her to too high, and so we felt very comfortable starting her on dual oral combination therapy.
And then we worked very closely with her and her local doctor. And you know, we don't have all the solution, there are still challenges, but we try very hard to come up for - with plans for patients that are feasible. And so we have now arranged follow-up with her, kind of with a variety of methods. We try to do as much as we can with video visits, but we have tried to incorporate her local primary care provider who, you know, really wants to do the right thing by her and can see her as often as needed and do lab testing and the like there. He helps us manage diuretics. And then we still need to see her periodically. We occasionally need to see her in the center, and she needs occasional echo’s and right heart caths that we would prefer to do. But in collaboration with her primary care provider and the use of video visits, we're trying to minimize the amount of trips that she needs to make down to Ann Arbor.
So social determinants of health are really challenging sometime, and we need to be creative about solutions and try to figure out what works best for the patient. I think in this instance, it was a really great outcome that we were able to provide her the center-level care with the minimum amount of trips down to the center and really keep a lot of her care locally. So it's working out really fantastic for her.
So thank you for joining me with this case presentation on some of the challenges we have with our underserved populations.
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