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GP beware - cardiology

Consultant cardiologist Dr Jerome Ment discusses three cases of mimic symptoms that can cloud a diagnosis

Case 1

Mr F, a 69-year-old retired engineer, presented to his GP with a three-week history of worsening breathlessness, an intermittent cough and some wheezing at night. His symptoms had come on while on holiday recently, but had become worse on returning to the UK. He had a history of hypertension that was usually well controlled, but had not attended for regular blood pressure checks in the last 12 months. He was an ex-smoker and had no other past medical history of note.

A brief examination revealed a soft systolic murmur and occasional rhonchi, but was otherwise unremarkable. The GP diagnosed COPD, pending spirometry, and initiated bronchodilator therapy in the form of a salbutamol inhaler.

A week later, Mr F returned with worsening symptoms of breathlessness. His GP added a course of oral steroids and arranged to see Mr F back the following week. Two days later, Mr F was admitted to his local hospital with acute pulmonary oedema requiring intravenous diuretics and a prolonged hospital stay.

GP’s diagnosis

Chronic obstructive airways disease secondary to smoking.

Actual diagnosis

Congestive heart failure secondary to ischaemic heart disease.

Clues

Persistent unexplained breathlessness, particularly in a patient with risk factors and a systolic murmur.

Take-home message

Cough and wheeze may be presenting symptoms of heart failure. Peripheral oedema is often a late finding. The diagnosis of heart failure should always be considered in patients with recent onset of breathlessness, particularly if there are risk factors for, or a history of, ischaemic heart disease. Clinical findings in support of the diagnosis are an elevated venous pressure, a displaced apex and the presence of a mitral regurgitation/systolic murmur.

Case 2

Mrs L, a 48-year-old primary school teacher, arranged to see her GP with a one-week history of lethargy, fever and muscle aches. Four weeks previously, she had visited her dentist with a dental abscess, but otherwise reported no other past medical history of note apart from mild seasonal asthma. On checking her records, a history of minor mitral valve prolapse was noted on an echocardiogram five years previously, but this was not followed up further. Her GP diagnosed influenza and advised bed rest and paracetamol.

The following week she returned to the surgery, although on this occasion she did not see her regular GP. Her fever and lethargy symptoms had continued, but she had also begun to experience some breathlessness and a cough. Examination of her throat as well as otoscopy was unremarkable. Auscultation of the chest revealed some wheeze and a few crepitations. The GP diagnosed a chest infection and prescribed a course of amoxicillin with arrangements for a further appointment the following week if her symptoms did not resolve.

That weekend, Mrs L went to her local A&E as her breathlessness had become dramatically worse. A chest X-ray demonstrated pulmonary oedema and further subsequent investigation revealed mitral valve endocarditis with severe regurgitation. She went on to mitral valve replacement and made a good recovery.

GP’s diagnosis

Chest infection, recent viral illness.

Actual diagnosis

Infective endocarditis of the mitral valve with severe regurgitation.

Clues

Unexplained pyrexia in a patient with even minor valve disease, along with a recent dental infection.

Take-home message

Infective endocarditis, although rare, is a serious life-threatening condition with mortality rates of over 25% in some studies. The presence of an ongoing fever should prompt formal cardiac auscultation to identify new murmurs. Elevated inflammatory markers and night sweats should also further raise the index of suspicion. Once suspected, prompt referral should be made for echocardiography and discussion with a local cardiologist is advised.

Case 3

Mr M, a 56-year-old data clerk, saw his GP at the insistence of his wife after he had noticed discomfort in his neck while watching his local football team at the weekend. His symptoms had come on gradually over six weeks, but were becoming more severe.

On further enquiry, he had also noticed similar symptoms on one occasion during an argument at work. He denied any exertional symptoms but admitted to having a very sedentary lifestyle. He had recently given up smoking and was also known to have a slightly elevated cholesterol, which was being managed through dietary modification, but was otherwise well on no regular medication. He was not a regular attender at the surgery and had missed an appointment earlier in the year for a repeat cholesterol and blood pressure check.

Physical examination was entirely unremarkable apart from an elevated BMI. Mr M’s GP diagnosed muscular neck pain related to poor posture at work. He prescribed analgesia in the form of ibuprofen and made arrangements for physiotherapy at the local hospital.

A week later, Mr M presented with acute inferior MI to his local hospital and was treated with primary angioplasty and stenting of his right coronary artery.

GP’s diagnosis

Muscular neck pain.

Actual diagnosis

Recent-onset angina.

Clues

Pain in neck or throat brought on by emotional stress in a patient with risk factors.

Take-home message

Angina most commonly presents with chest pain, but can cause localised discomfort anywhere from the jaw line to the navel. Symptoms can be brought on by both physical and emotional stress (‘test-match angina’), and should prompt further evaluation, particularly if risk factors for ischaemic heart disease are present.

Dr Jerome Ment is a consultant cardiologist at the Heart of England NHS Foundation Trust

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Readers' comments (15)

  • It seems that GPS haven't picked up any of the three conditions & that must be cause for concern.

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  • Those cases above with those initial symptoms on presentation with hindsight- which is a powerful tool, seems highly suggestive of the eventual diagnosis. However we all know how non-typical presentation of typical diagnosis can fool the best of doctors. We have all been here,no?

    Afterall,, unlike carpentry and plumbingfor example,if we cut something or treat something, there is often a lot of uncertainty associated with it, as it is with the human body.

    To err is human, to learn from our mistakes makes us better considerate humans and better considerate doctors.

    To punish when we err, is to assume we are not human. It debases us all, including the "Punisher".

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  • It is notable that these patients presented in hospital when their symptoms were more pronounced and the hospital of course had the benefit of investigations at hand immediately to elucidate diagnosis.
    This should not be a " GPS are useless"exercise as Gpd often have picked up things that hospital colleagues have missed despite the fact they only have minute parts of the body to concentrate on and all the high faluting equipments they have. But a " let's learn from presentations of diseases which is not run of the mill or usual

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  • If you don't think of it you will never diagnose it...

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  • Case 4
    Miss M, 10 year old attended GP with a 4 hour history of mild fever. Temperature 38.1°C. Examination otherwise normal. Parent advised to seek further assessment if any deterioration.
    24 hours later child presented at A+E with non-blanching rash.

    GPs diagnosis.
    Viral infection.

    Actual diagnosis.
    Meningococcal septicaemia.

    Clues
    It's bound to happen eventually.

    Take home message
    You haven't done anything wrong but you will still never forgive yourself.

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  • Drachula

    You cardiologists need to come and experience life at the coal face. Would you like me to send you every case of neck pain, chest infection and lethargy just in case it is something unusual. We had a case just like 2, but with no clues, and I frequently send case 3 people up based on history and vague pains, but in this case he would have had his MI before being seen in the new onset angina clinic.
    I could send everyone up to A&E and completely overwhelm you, but we have 111 for that already.

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  • Colleagues,
    The consultant is in NO way undermining gps..He is only sharing experiences. We had such discussions in grand round in medical schools-overseas.

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  • have seen a patient with RA admitted to MAU , I usd to work as a nurse there, with neck pain- no other risk factors- told by senior staff , that it was her RA , but my gut feeling was that something wasn't quite right despite so I did an ecg and it showed she had an MI

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  • No help at all! Was this purely a chance to bash GPs for not spotting atypical presentations quick enough? You're the expert and it's easy to get the diagnosis first time when the presentation becomes more obvious! Grind your axe somewhere else!

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  • Interesting cases thanks for highlighting

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