Correspondence
Clinical Problem-Solving: Diverted by the Chief Complaint
N Engl J Med 1995; 333:1424-1426November 23, 1995
- Article
To the Editor:
The Clinical Problem-Solving article entitled “Diverted by the Chief Complaint” (July 6 issue)1 deserves the name “Diverted by Our Major Mistake.”
It is amazing that a pathology report of a liver biopsy and not the distended jugular veins of the patient led to the correct diagnosis of constrictive pericarditis. The excuses of the authors (“it is not surprising that the correct diagnosis was overlooked initially,” “it is hard to fault the physicians,” and “clinicians often overlook elevated venous pressures”) are unacceptable: detection of engorged cervical veins is within the competence of medical students and should not be reserved for the “privileged” consultant cardiologist of a respected medical center “who had the advantage of being asked to evaluate a patient with passive hepatic congestion.” It is not “the last clinician to see the patient [who] often has such advantages” in reaching the diagnosis; it is the advantage of the first physician who really examines the patient. What is troublesome about this case is the fact that “a series of physicians,” and not a student, violated a basic medical rule — namely, to examine patients carefully. Despite this, the authors lend legitimacy to this below-acceptable-standard medical practice by trying to convince us that it is a common practice for clinicians to conduct “focused physical examinations as they pursue particular hypotheses.” This “educational message” to the readers of the Journal should be condemned and not encouraged, accepted, or promoted.
Finally, the authors were unable to explain the flushing experienced by the patient. The simplest explanation that comes to mind is that slight efforts of the patient were followed by increased blood return to the right ventricle. Because of the constrictive pericarditis and the transient inability of the right ventricle to cope with the excess of blood, drainage of the blood from the head and face was slowed, causing venous engorgement and the observed “flushing.”
1 ReferencesDan Aderka, M.D.
Tel Aviv Medical Center, Tel Aviv 64239, Israel1
Pauker SG ,Kopelman RI ,Lechan RM . Diverted by the chief complaint. N Engl J Med 1995;333:45-48
Full Text | Web of Science | Medline
To the Editor:
This Clinical Problem-Solving case is an example of multiple unnecessary tests being done on a patient when a routine physical examination should have dictated otherwise. The patient had several laboratory tests, computed tomographic scanning, and a liver biopsy before a cardiologist noted neck veins distended to the angle of the jaw and the presence of Kussmaul's sign, suggesting constrictive pericarditis as a diagnosis. These findings were no doubt present all along.
The commentator notes that it is “hard to fault the clinicians” for missing the diagnosis. Obviously, it was important in this case to rule out pheochromocytoma before sending the patient to surgery; however, the point here should be that with a patient with new hypertension, it is absolutely necessary to perform a careful physical examination before subjecting the patient to invasive, potentially harmful procedures. Dr. Osler must be turning over in his grave.
Chester B. Good, M.D., M.P.H.
University of Pittsburgh Veterans Affairs Medical Center, Pittsburgh, PA 15240To the Editor:
After we read the case of the obese patient whose constrictive pericarditis eluded diagnosis until after clinicians went down several blind alleys, two pieces of clinical lore came to mind. First, when venous pressure in the neck is not assessable, physicians can still occasionally estimate systemic venous pressure by raising the patient's arm slowly until the veins in the arm or hand collapse and then measuring the vertical distance from this point to the level of the right atrium.1
Second, the clinicians caring for this patient, who were tipped off to the correct diagnosis only after a liver biopsy showed congestion, may derive some comfort from a case of constrictive pericarditis discussed in the Journal in 1984.2 In that case, Dr. Roman DeSanctis quoted the old clinical adage of Dr. Conger Williams that “no patient was ever operated on for constrictive pericarditis unless there had previously been a liver biopsy.”
Thus, despite medicine's remarkable recent advances, the current case shows that the old wisdom is still valuable — which should not be surprising, given the much older wisdom that “there is no new thing under the sun.”3
3 ReferencesJohn G. Sotos, M.D.
Johns Hopkins University School of Medicine, Baltimore, MD 21205George A. Sotos, M.D.
9707 Medical Center Dr., Rockville, MD 208501
The blood vessels. In: DeGowin RL. DeGowin & DeGowin's bedside diagnostic examination. 5th ed. New York: Macmillan, 1987:412.
2
Case Records of the Massachusetts General Hospital (Case 27-1984)
Full Text | Web of Science | Medline3
Ecclesiastes i.8.
To the Editor:
Great case! However, I would like to comment on the statement made about the physical examination that “prominent A and V waves were present.” These physical findings would not be expected to be seen in a patient with constrictive pericarditis.1 Instead, a classic finding in such a case would be rapid X and Y descent in the jugular venous pulse. If both rapid X and rapid Y descents are present, they may produce a W-shaped pulsation in the jugular venous pulse. Prominent A and V waves are not at all characteristic of constrictive pericarditis. Prominent A waves are seen in conditions such as tricuspid atresia, right atrial myxoma, right ventricular hypertrophy, and atrioventricular disassociation, and prominent V waves are seen with severe tricuspid regurgitation.
1 ReferencesM. Haseeb, M.D.
Good Samaritan Regional Medical Center, Mt. Vernon, IL 62864To the Editor:
That asbestos-related pleural plaque formation and calcification can cause difficulties in clinical cases is well known. Misunderstandings of the medical complications of asbestos exposure on the part of patients are common.1 Their introduction to respiratory medicine often happens when they undergo chest radiography for an entirely different reason and then are told (clumsily) that there is evidence of “asbestos” on their film. Did this clumsiness surface within the Clinical Problem-Solving case too? Pleural plaques are remarkably common in the Glasgow area, where at one time one third of the world's ships were constructed, but thankfully the related interstitial lung disease of asbestosis is not, and the two should never be confused.
1 ReferencesKenneth Anderson, M.D., M.R.C.P.
Glasgow Royal Infirmary, Glasgow G4 OSF, United Kingdom1
Anderson K ,Moran F . Tobacco and asbestos litigation. Lancet 1986;2:1038-1038
CrossRef | Web of Science | Medline
To the Editor:
Pauker, Kopelman, and Lechan point out the diagnostic difficulties that can occur when the principal findings are not the cardinal manifestations of a disease process. In their case, episodic flushing and hypertension diverted their attention from the eventual diagnosis of constrictive pericarditis by suggesting diagnoses of pheochromocytoma, carcinoid syndrome, and mastocytosis. Two important points should be made. First, although both carcinoid tumors and systemic mast-cell disease are clearly associated with paroxysmal flushing, these illnesses are frequently associated with hypotension because of their association with the secretion of vasodilatory hormones (e.g., prostaglandins, kinins, and biogenic amines).1 Lightheadedness, orthostasis, and syncope can occur after episodes of flushing due to systemic vasodilatation with a precipitous decrease in blood pressure. Unlike pheochromocytoma, hypertension is not a characteristic feature of these disorders. Second, the discussion fails to include other possible causes of these symptoms that are probably far more common — namely, prescription and nonprescription medications. In particular, niacin (nicotinic acid) comes to mind. Pharmacologic doses of niacin are known to be associated with flushing and hepatocellular dysfunction. Niacin is also known to provoke insulin resistance and may be associated with hypertension in obese patients with syndrome X. Many patients who ingest multiple-vitamin preparations will not consider niacin a “drug” unless specifically asked, and this should certainly be checked before invasive diagnostic procedures, such as liver biopsy, are considered.
1 ReferencesSteven J. Lomasky, M.D.
Endocrinology and Diabetes Associates of Long Island, Rockville Centre, NY 11570Author/Editor Response
The authors reply:
To the Editor: We are pleased that this uncommon presentation and cause of constrictive pericarditis provoked such vigorous discussion of common problems that arise in clinical problem-solving. Unfortunately, neither physicians' reasoning nor their physical examinations are perfect. Although physical findings have been categorized in terms of their sensitivity and specificity far less often than have diagnostic tests,1 experienced clinicians understand that important findings are sometimes missed or misinterpreted. As Sotos and Sotos point out, the difficulties involved in diagnosing constrictive pericarditis and identifying marked jugular venous distention are well recognized in standard textbooks. Although this patient had been examined over the years by an experienced internist and, during the acute problem described in the case presentation, by several senior clinicians, the jugular venous distention went unrecognized by most.
We agree with Dr. Haseeb that the clinicians' description of the jugular wave form might have been better described in terms of the valleys rather than of the peaks, but the observation was clear — the venous pulses were active and prominent. When presented with a large amount of potential information that might be gathered, we believe that clinicians must be selective: the astute clinician is perhaps just better at selecting what evidence to gather. In a patient who presents with crushing chest pain, a careful examination of the epididymis might not be the highest priority. Furthermore, as has been often discussed in the Clinical Problem-Solving series, imperfect data are always interpreted in some context. Since this patient's presentation was clearly atypical for constrictive pericarditis and the diagnosis did not enter the clinician's mind, it is not surprising that a cursory examination of the patient's neck showed no obvious elevation of the jugular venous pressure.
We selected this case partly to emphasize some unusual consequences of asbestos exposure, but we did not suggest the presence of interstitial lung disease. As Dr. Lomasky suggests, clinicians must always be alert for the side effects of medications, either those they themselves prescribe, those prescribed by other clinicians, or vitamins and medications that patients take on their own.2 In this case, the disappearance of the flushing and the hypertension after surgery argues that the constricting pericardium was, at least in part, the cause of the patient's hypertension and flushing, which, by the way, was described as red and neither violaceous nor plethoric. Although mastocytosis and carcinoid syndrome are both usually associated with hypotension, markedly elevated diastolic blood pressures have been observed in mastocytosis, perhaps as a result of vasoconstrictor metabolites of prostaglandin D1.3 Similarly, carcinoid crises can be manifested as hypertension, perhaps related to vasoactive substances, such as endothelin-1.4
4 ReferencesStephen G. Pauker, M.D.
Richard I. Kopelman, M.D.
Ronald M. Lechan, M.D.
New England Medical Center, Boston, MA 021111
Koran LM . The reliability of clinical methods, data and judgments. N Engl J Med 1975;293:642-6, 695
Full Text | Web of Science | Medline2
Wilkin JK . Flushing reactions: consequences and mechanisms. Ann Intern Med 1981;95:468-476
Web of Science | Medline3
Roberts LJ II . Carcinoid syndrome and disorders of systemic mast-cell activation including systemic mastocytosis. Endocrinol Metab Clin North Am 1988;17:415-436
Web of Science | Medline4
Murakami O ,Takahashi K ,Sone M , et al. An ACTH-secreting bronchial carcinoid: presence of corticotropin-releasing hormone, neuropeptide Y and endothelin-1 in the tumor tissue. Acta Endocrinol Suppl (Copenh) 1993;128:192-196
- Citing Articles (1)
Citing Articles
1
H. James Williams, Michael H. Weisman, Charles C. Berry. (1997) Breast implants in patients with differentiated and undifferentiated connective tissue disease. Arthritis & Rheumatism 40:3, 437-440
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