The Incidental Diagnosis

It was during my time as a House surgeon. I was posted in the internal medicine department. That day, I was posted to OP along with 2 of my batch mates. I was given a separate room at the OP entrance which was almost 10 feet from the Consultant Physician's room. My duty was to check vitals and fill up basic patient past, personal and family history to save time for consultant doctor. I sat in my room at almost 8.45 a.m. and was waiting for patients to arrive. Almost at 9.15 a.m., the first patient came. I did a check of his vitals, starting with body temperature, I took his pulse rate, respiratory rate, blood pressure, Oxygen saturation (SpO2), weight, height and calculated BMI. Then I noted his chief complaint and other relevant history and then sent him to the consultant's room. The same thing I had done with the next patient, the next patient and so on. The patient's flow started increasing slowly. At almost 11.00 a.m. the OP was overcrowded with many patients and their family members. Then came a young man with complaints of fever, headache, abdominal pain, diarrhoea.  He had a history of eating Panipuri in the street a week back. So, I suspected Typhoid / Panipuri disease and I checked vitals and I found some significant finding here (which I will reveal later) which I wasn't sure of. However, I mentioned the finding in the patient's OP sheet and started further examining the patient in the hope of finding rose spots, hepatomegaly etc.., However, I couldn't find any rose spots (Patient was dark skinned) but I found mild hepatomegaly. So, I recorded my findings. And I sent the patient to the consultant's room. 10 minutes later, the consultant sent a nurse and asked her to bring me. So, I stood up from my chair and started walking towards him. On my way to his room, I was scolding myself in my mind "Why did I mention the finding on the Patient's OP sheet when I was not even sure about it". I went into the room with some worry.

And I asked him why he called me. The consultant smiled at me and said to me that the finding was so faint that most of the doctors would have missed the finding, but he was so proud that I had found the finding and he praised me a lot in front of my seniors and batchmates.  So, I was very much relieved, knowing that I hadn't made any mistakes.

So now the big reveal is "The finding was a Mid-systolic murmur". As I suspected Typhoid, I checked for his pulse for relative bradycardia (Faget's sign) and I also wanted to listen to his heart sounds. So, I started auscultation and accidentally found Mid-systolic murmur, which was not Related to typhoid. So, I asked him for chest pain, shortness of breath, fainting, unusual sweating etc.., which he denied. So, I double checked his heart sounds and I still heard mid systolic murmur, so I mentioned it on his OP sheet.  

The consultant said he also heard mid-systolic murmur, so he asked the patient to get ECG and Echo along with other tests for his present symptoms (which was later confirmed to be typhoid). ECG showed classic dagger like Q waves and echo showed increased left ventricular wall thickness . A diagnosis of HOCM (Hypertrophic obstructive cardiomyopathy) was made with Cardiac MRI. He was treated for Typhoid and he was referred to a cardiologist for HOCM.

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