BMJ  2004;328:946 (17 April), doi:10.1136/bmj.328.7445.946-a

Commentary

An evolving picture

F D Richard Hobbs, professor of primary care and general practice1

1 Primary Care and Clinical Sciences Building, University of Birmingham, Birmingham B15 2TT f.d.r.hobbs@bham.ac.uk

The first 150 words of the full text of this article appear below.

It is pleasing to see such a flurry of responses on bmj.com espousing the importance of incremental problem solving and of clinical acumen. This interactive case was never likely to be "typical." As Abdullah Mohammmed comments, "the initial clinical findings seem contradictory."1 This is so often the case with medicine, and observing symptoms and signs over time remains an essential diagnostic tool, especially in primary care. Most correspondents were quickly on track over the red herring of heart failure. Bruce Lennox says, "cardiac failure was never likely" because of the absence of risk factors for coronary heart disease, and others point to the normal electrocardiographic results. However, only unequivocal electrocardiograms read by specialists can rule out heart failure and, as in this case, specialists often disagree.2

Considering heart failure was entirely reasonable on the initial presentation, despite the lack of risk factors. Typical presentations of coronary heart disease are likely . . . [Full text of this article]


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