Wednesday, June 8, 2011

Interesting Case

We had a 16 year old boy that came in with severe neck pain/stiffness and high fevers. It was assumed he had meningitis and he underwent a lumbar puncture and was started on antibiotics. He continued to decline over the next several days, as his pain worsened and his fevers persisted.

On rounds one day the American medical student took his blood pressure and it was 120/10. She thought she was messing something up so she asked me to take it. I got a reading of 120/0. This is not normal! The lower number should be 40-60 mmHg. The difference between the top and bottom number (systolic and diastolic blood pressure) is called the pulse pressure. This guy had a huge pulse pressure of 120 mmHg.

We quickly moved to a cardiovascular exam, as there are only a few things that can cause such a blood pressure. Just placing your hand on the patient's chest you could feel a thrill (buzzing sensation) of a heart murmur. You could hold your stethoscope off the chest and here a murmur. He had the loudest murmur I think I have ever heard.

On further examination we found that he had all the classic findings of severe aortic regurgitation. He had the pistol shot pulses, dancing carotids, bobbing head, and tender splenomegaly. We ordered a stat echo and found that he had severe aortic valve disease with aortic stenosis and regurgitation. He was also in heart failure secondary to his valvular disease.

Looking back through the chart multiple people had written: Cardiac examination normal with no murmurs. It made me realize how in medicine we can get fixed on a diagnosis and forget to look for anything else. This guy's heart disease was obvious once you took the time to listen, but everyone thought he had meningitis so no one really paid any attention to his heart.

We think the patient has an infection on his heart valve and is throwing small emoli (clots) all over his body. Unfortunately, there is very little to do for people in Kenya with valvular disease. There is no open heart surgery in Eldoret. It is very unlikely that this young boy will survive for very long. We are trying to aggressively treat any infection that might be present to help his odds of survival.

The physical exam findings here are absolutely just have to look for them!

1 comment:

  1. Okay, so I know that this is a really tragic case and that there's not much you can do. But, they shouldn't make a disease with such fun sounding symptoms as "dancing carotids, pistol shot pulses and bobbing head." Right?