Lip swelling

The message on my door was: “Mrs. Grantham wants biopsy report sent to dermatologist. None in her chart.” 

I buzzed the triage nurse who explained that Mrs. Grantham had called our office because she had a follow-up appointment with a dermatologist the next day, and she wanted to make sure the dermatologist had the biopsy report. At the time of her initial visit to the dermatologist, he had been undecided about a diagnosis because he had not yet received the biopsy report and had therefore scheduled a follow-up visit.  The triage nurse couldn’t find a biopsy note or path report in the chart and had forwarded the message to me. Reviewing the chart (between patients) I learned:

  • We had not sent a biopsy report because we didn’t have one.
  • We had not referred her to the dermatologist and had no note from the dermatologist’s initial visit.
  • There was a note from the oral surgeon who had seen her. The oral surgeon’s note said she had been referred to him by her dentist because of concern about a facial injury from a motor vehicle accident (MVA), that he had found nothing on exam and had done a biopsy, and that he had referred her to the dermatologist because he didn’t have a diagnosis. 
  • We had no ED note or dermatology note and no information about a motor vehicle accident. I told my staff to contact the oral surgeon and make sure he faxed a copy of the biopsy report to both us and to the dermatologist. I also told them to get me a copy of the ED note and dermatology note. 

The logistical problem was solved. The clinical problem was not.

At the end of the day, I went back to review the notes the nurses had obtained while I was seeing patients that afternoon.  The whole story, as told in two ED notes and notes from the oral surgeon and dermatologist, was pretty straight forward.

She had been seen in the ED because of a minor motor vehicle accident that had resulted in a small laceration on the inside of her upper lip when her face hit the steering wheel. It had required two small self-dissolving sutures. She had returned to the ED several days later with some facial swelling and was treated with antibiotics for what they presumed was a wound infection. She had continued to have intermittent swelling and returned to the ED twice. The second time they suggested she see her dentist or an oral surgeon about a possible dental injury. The dentist saw her but found nothing wrong and arranged for her to see the oral surgeon. The note from the oral surgeon said that she had been referred to him by the dentist for a biopsy after the dentist could find no cause for her swelling. The oral surgeon’s note said her exam and the biopsy were unrevealing, but that there was no swelling at the time of the visit, and that he had referred her to the dermatologist for further evaluation of ‘intermittent lip swelling.’  The dermatologist noted that she had intermittent painless swelling of the upper and sometimes lower lip without redness, that he doubted infection, but that he did not have the pathology report to review so did not want to make a diagnosis.

Hmmm. Painless intermittent swelling of the face, especially around the lips.  I checked the medication list: lisinopril 10 mg daily for high blood pressure had been started about 6 weeks prior to her motor vehicle accident.

I called her, confirmed the history and time line, asked about other symptoms or physical events (none), and explained that a condition called angioedema was a known side effect of lisinopril, that it occurred in roughly 1 in 1000 patients, and that her biopsy and multiple exams had not seen anything else as a potential cause to worry about. I suggested that she stop the lisinopril and return to the office two weeks later to confirm that her angioedema had stopped and to reassess our plan for treating her BP.  She readily agreed and cancelled the visit with the dermatologist.

When I saw her roughly 3 weeks later her BP was 148/90 and her angioedema had stopped. We talked about several options for her BP and she decided to work “really, really, really hard” at controlling it without medication. Three months later she was exercising nearly every day, had cut her alcohol back to a small glass of wine at dinner several days a week, was following the DASH diet, and had lost 11 pounds. Her BPs at home were consistently in the 130s/80s and her BP in our office that day was 136/84. 

She asked me why I had been able to figure it out without seeing her, but that 2 ED doctors, a dentist, an oral surgeon and a dermatologist had not. I explained that, as a PCP, I looked for overall patterns, while each of the other clinicians she had seen were inclined to look at and think about a much narrower set of options.  For me, the pattern of her symptoms and the presence of an ACE inhibitor on her medication list suggested the diagnosis quite strongly. She expressed considerable irritation at the fact that she had been asked to give her allergies and list all her medications at each of her visits. Why, she wanted to know, did they collect that information if they weren’t going to use it?

Post script: her lifestyle changes and their benefits have been durable. She somewhat sheepishly told me at a routine visit a year or more later that it was the cost of multiple visits and time lost from work that motivated her to make and sustain the lifestyle changes that I had been suggesting for years, without success. Only half jokingly, she asked: “Does that make me a bad patient, or does it make you a bad doctor?”


 

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