Nancy, a 58-year-old farmer, presented with a 12-month history of exertional dyspnoea and angina. When she subsequently presented with episodes of dizziness a classic triad came to mind. Dizziness/syncope + angina + exertional dyspnoea → aortic stenosis (of course this constellation of symptoms can occur with anaemia). On auscultation there was the harsh crescendo-decrescendo systolic ejection murmur of aortic stenosis that would remind me of a steam train chuffing uphill or distant barking of a dog (strange associations from student days!).
I was concerned and sent her to a visiting physician for an opinion about further investigation with a view to surgical repair. He thought that the condition was not sufficiently severe to warrant further investigation stating ‘we’ll still play it by ear’.
About three months later I received a call to attend to an emergency in the family’s cowshed. While milking, Nancy developed chest pain and then collapsed and was unconscious for a few minutes. As she lay in the fresh cow manure and mud of the milking shed she looked sick, humiliated and was hot to touch (her temperature was 38.7 °C). There was no paramedical service at that time so I performed an ECG with my portable unit. There was no evidence of an acute coronary ischaemic episode although I could not exclude it.
I was very concerned and rang the admitting officer of our usual referral metropolitan hospital to inform him that I would be pleased if he could admit my patient with the probability diagnosis of subacute bacterial endocarditis. ‘What makes you think that, Doctor?’ came the response in cynical overtones, as though a remote rural doctor was incapable of such a diagnosis. However, he agreed to admit Nancy, who was transported by a regional ambulance. She was admitted with PUO. After two or three days of procrastination about the diagnosis and management Nancy suffered an embolic stroke resulting in left hemiparesis. It was due to a mycotic embolus from a ‘vegetating’ aortic valve. All hell and penicillin broke loose! The organism was Streptococcus viridans. After seven months she was discharged back to my care with a prosthetic valve, hemiplegia and cardiac failure.
DISCUSSION AND LESSONS LEARNED
The plight of the busy stressed GP with a seriously ill patient and also the admitting officer with limited available hospital beds is highlighted.
It could be argued that an experienced general practitioner has a greater diagnostic acumen than less experienced hospital interns and resident medical officers and their skills should be given due recognition.
The problem of procrastination with serious and potentially life-threatening infections is reinforced yet again. It is sometimes most appropriate for doctors to act as advocates for their patients if they consider that the medical system is not acting with due urgency.
This case also reinforces the valuable discipline of learning aide memoirs such as diagnostic triads or tetrads ...
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