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axillary node now appears: any comment on raised JVP?
- Ramakant sharma (19 April 2004)
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Learning Points
- Ashok Chandra (19 April 2004)
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Importance of Clinical Signs
- Abdullah A Mohammed (19 April 2004)
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Ramakant sharma, halton general hospital runcorn wa7 2da
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sir, this case study from the beginning was misleading. authors now say they could palpate an axillary node(did they miss it in the beginning?)? what about the raised JVP? did that persist? are they trying to tell us that the diagnosis was superior vena cava obstruction? if that is the case, than a careful examination would have proved that she was not in heart failure. if there was no SVC obstruction, then how can you explain raised jvp? since the publication of this study, i am trying to stress about lack of proper examination details given to readers, and that has been proven beyond doubt with the publication of concluding part. thanks Competing interests: None declared |
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Ashok Chandra, Prof. of Medicine K.G.Medical University, Lucknow 226 003, India
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The learning exercise has been excellent and there are two points which need highlighting. Firstly whenever one is faced with such a clinical delimma one has to plan out a time schedule for evolving investigations and this can be cut short if any emergency develops as in this particular example there could be severe dyspnoea, arrythmias or low output syndromes.The diagnosis is an evolving one and needs to take into account newer symptoms or the lack of ANTICIPATED RESPONSE. Secondly I agree with the observations of Prof.Ed Perle also in this issue of eBMJ that Pathophysiology is important, however the whole diagnosis needs to be unravelled and proved. Apart from this it consists of the Site-in this case the Pleura and Lymphnodes and ? Liver, Spleen and the Blood; the Nature of disease being Lymphoma and finally the fourth part of the diagnosis which makes it complete is the Functional disturbance which goes a long way in helping to decide the modality of therapy. For a complete diagnosis all the 4 parts are important. Competing interests: None declared |
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Abdullah A Mohammed, Clinical Research Fellow The Cardiothoracic unit,Northern General Hospital,Sheffield ,UK
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Douglas Lowdon and Marion McMurdo's interactive case report has generated interesting and healthy responses from junior as well as senior physicians . The change of diffrential diagnosis which carries with it changes in investigation and management is typical of such cases presenting to the clinican .However ,I take issue with the authors in the the lack of accuracy in presenting the clinical signs the patient had which are fundamental to assembling a clinical diffrrential diagnosis.I can undestand deliberate omissions in writing up the case in order to make it sufficiently vague to generate active thinking and debate by their readers.I can't see however,how this patient could have had hard clinical signs that completely contradict the diagnosis.The two important examples are raised jugular venous pressure and pansystolic murmur.Niether of those signs can be expalined by the final diagnosis.In the case of raised jugular venous pressure even if there was a degree of superior vena cava obstruction ,this should not be confused with raised jugular venous pressure. Jugular venous pressure has distinc two waves which vary with respiration in contrast to generalsed venous engorgment of the head and neck veins that occurs with superior vena cava obstruction which is associated facial swelling and realted symptoms.It is of course possible for the jugular venous pressure waves to be difficult to see especially in an obese patient ,but that is quite diffrent from the positive reporting of the sign.The patient had normal renal and heart function and she had been losing fluid and weight which makes the jugualr pressure to be likely to be in fact low.The pansystolic murmur on the other hand,if reported accurately is always pathological indicating mitral regurgitation.Short systolic murmurs are quite common in normal physiological states or in conditions associated with sinus tachycardia but those are unlikely to be mistaken with pansystolic murmur that extends throughout systole. Although evidence and clinical experience teaches us that the use of clinical assessment,chest-XR and resting ECG used together are as reliable as an echocardiogram in diagnosing heart failure,Clinicians are too reliant on echocardiograpyhy to daignose heart failure.The basic principle of a good clinical assessment remains at the core of medicine. Competing interests: None declared |
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