Cannot Miss Diagnosis

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Six Pís to watch out in Atrial Fibrillation
Cannot Miss Diagnosis No.3

Section Editor: Prof. T.K.

Partha Sarathy

A Family Practitioner was asked to pay a visit to his patient; a 64 year old male who has been coming on and off to his clinic for follow up of his hypertension,

diabetes and cardiac problems. Apparently from the night before, the patient was not well and was having several vague complaints including tiresomeness, leg pain and lethargy.
The family practitioner was aware of his past history very well because
of his long association. Patient is a known diabetic for over 15 years and has been on oral hypoglycemics. He has hypertension and 7 years ago he had triple vessel disease for which coronary bypass surgery was done. Since then he has been on medications which includes oral hypo-glycemics, 5 mgs of Enalapril for hypertension, one tablet of Digoxin (0.125 mg) and one tablet Aspirin 75 mg a day. He was able to take care of himself to a great extent and this was the first time the family had asked the family practitioner to visit the patient at home.
On arrival the doctor found the patient was resting in bed and was not quite comfortable in talking to the doctor as he normally used to be. He wanted to be left alone so that he could sleep. Family Practitioner conducted the physical examination. He was breathing normal and there was no cyanosis.

The heart sounds were irregularly irregular. The doctor was reminded of the fact that he had atrial fibrillation in the past 3 years for which he was placed on Digoxin. His blood pressure was 160/96 mmHg. Pulse was irregularly regular. There were no rales or rhonchi heard over the lung fields. Abdomen was soft. There was no palpable mass or tenderness. There was no rigidity or guarding. Liver and spleen were not palpable. Patient being somewhat lethargic, a thorough neurological examination was not conducted. However, he was able to move all the limbs and his speech was normal. The practitioner suspected that he might have diabetes related problems; perhaps, hyper-glycemia and ketosis. He recommended that the patient be shifted immediately to the hospital, where he can arrange for further investigations and consultations as necessary. He was managed to convince the patient and the family members to shift the patient to his nursing home, which took about an hour.
On arrival at the nursing home, a cardiogram was performed which showed evidence of atrial fibrillation. Chest x-ray was unremarkable. Urinalysis was unremarkable. There was no ketone in urine. The blood sugar was 167. Electrolytes were within normal limits. But the patient continued to complain of leg pain, particularly on the left side and wanted to rest more. The General Practitioner started to examine him again from head to foot and he found that left leg and foot appeared to be some what hyperemic and towards the toes the colour was somewhat dusky. Naturally he expected ischemic changes and examined the peripheral pulses on both the sides more carefully. He found that the popliteal pulses as well as the pedal pulsations (dorsalis pedis and posterior tibial arterial pulsations) were absent on the left side and definitely present on the right side. The superficial femoral pulsation on the left side was less prominent compared to the right side. Given the history of past coronary artery disease, ongoing atrial fibrillation, and the present condition, the doctor immediately felt that, this could be a case of arterial embolization to the left lower extremity vessels which is responsible for these changes. He was also aware that prompt intervention and removal of the embolus could mean improvement of circulation and preservation of the leg. He knew that heparinization is the first step he should take in preventing further propagation of the clot and he ordered a bolus dose followed by I.V. heparin therapy.
While his assistants and the nurses were preparing for the same he made a call to his consultant vascular surgeon to come as soon as possible to see the patient. The vascular surgeon who arrived shortly, examined the patient and agreed with the family practitioner that this case is strongly indicative of occlusive Thrombo Embolic disease of the left femoral system and that an embolectomy under local anesthesia was indicated. Given the patientís general condition, past history, as well as the limitations of the surgery, local anesthesia was preferred by the surgeon. He discussed with the family and the family practitioner that even though an angiogram would provide a conclusive diagnosis it will be time consuming and not necessary in his condition. With the help of doppler he assessed his cardiac status and suspected left atrial thrombus. He was also able to demonstrate the difference between right and left lower extremity vessels by doppler studies. All these took a short time by which period the theatre was made ready and the patient was shifted. Under local anesthesia, the surgeon explored the left femoral artery and after gaining proximal and distal control, made an incision in the artery and opened the same. Using a Fogatry balloon catheter he was able to pass through the vessels and removed large clots. The embolus was sent to pathology for confirmation to rule out tumour cells, because occasionally tumours can also embolise.
After the procedure was completed gradual return of the pulse was felt and there after patient started to improve. His diabetic as well as cardiac status were carefully monitored and the cardiologist decided to keep him on long term anti-coagulant therapy to prevent such embolisms in future.

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Monte 

probably i m also facing the same problem since yesterday, so can you tell me about the duration until which such torsions in testes are reversible. please reply me quickly. here also the swelling is observed first time in my 19 years & is a bit painful too.

soroush 

it was better if you mentioned that his pain was acute onset or not

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