Po1646 50 Years Old Male, With Hbp Who Complains Of Insomnia And Long Standing Palpitations

Rafael Luquin-Martínez1, Almudena Salas-Sola2, M. Beatriz Guerrero-Díaz3, José López-González3, Jose-Miguel Bueno-Ortiz4, Encarnación Ros-Martínez5, Alfonso Piñana-López6, Jesús Fernández-Lorencio7, Rosario Morales-López8 e Concepción Alonso-Garcia9
1Health Centre Cartagena-Oeste; 2Resident physician of Family Medicine Health Centre East-Cartagena; 3Physician Family Medicine Health Centre East Cartagena; 4CENTRO DE SALUD DE FUENTE ALAMO. MURCIA. SPAIN.; 5Family physician at the health centre Cartagena West; 6family physician at the health centre Cartagena West; 7Physician Family Medicine Health Centre West Cartagena; 8Family Physicians of Health Centre West-Cartagena; 9sms
50 years old male, ambulance driver, visits his GP complaining of insomnia and long standing palpitations since two weeks. No chest pain, long standing moderate effort dyspnoea. No orthopnoea, no paroxistic nocturnal dyspnoea, no edema. He has HBP, treated with ACE and diuretics for 5 years, well controlled, takes 550 gram alcohol/week, smokes 34 pack/year. Medical exam:cardiac ausc: regular, systolic murmur III-IV/VI in mitral focus that irradiates to other foci. 65 beats/min. Pulmonary ausc: NAD. Abdomen NAD. Lower limbs: symmetric and normal pulses. No oedemas. Blood test: High transaminases and thrombocytopenia, N other AD (thyroid hormones). EKG:Sinusal rhythm, 75 beats/min, QRS + 90°. Incomplete R branch blockage, L Ventricular Hypertrophy (H) (Cornell criteria) and negative T waves (V4-V6). Chest X-rays: cardiomegaly without redistribution of pulmonary flow. We should consider systolic murmur differential diagnosis: aortic valve stenosis, mitral regurgitation, obstructive H cardiomyopathy (OHM) and functional ejective murmurs. We produced as provisional diagnosis: chronic excessive alcohol intake with hepatitis, tobacco addiction, HBP, cardiac H (systolic murmur and EKG abnormalities). We referred the patient to cardiologist who ordered:1)Echocardiography: Severe L ventricle walls H, more intense in septum. Severe L atria enlargement. R cardiac cavities NAD. Mitral valve: degenerative signs, opening preserved, intense SAM that with L Ventricular H produces dynamic obstruction in L Ventricular IT on moderate scale at rest. Sclerotic Aortic Valve. Light Aortic failure.2)Full abdominal ultrasound: NAD.3)Stress cardiac ultrasound: 3min ex (Bruce protocol), stopping because dyspnoea. Negative clinical response to angina.4)Electrophysiological study NAD.
FINAL NEW DIAGNOSIS: OHC, mitral regurgitation, HBP grade 3. In adults, functional systolic murmurs can usually be distinguished from organic murmurs. Pathological murmurs frequently have one or more associated clinical abnormalities. If a clinician determines a murmur is benign, results of echocardiography are very likely to be normal, especially in young and middle-aged adults. According to current guidelines, echocardiography should not be ordered for “innocent” systolic murmurs in patients who are asymptomatic and have otherwise normal findings on examination. If patients with functional systolic murmurs could be identified and not routinely referred for echocardiography, great cost savings could be realized.
High blood pressure; systolic murmur; primary health care; insomnia.