An evolving picture

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 with low ejection systolic heart failure but less so with normal ejection fraction heart failure, as several respondents pointed out. I agree with Muntasir Abo Al Hayja that it would have been nice to measure B-type natriuretic peptide, since this assay seems to be a promising test for exclusion of heart failure.³

Most respondents were, however, soon on the right diagnosis from the normal echocardiography result and the presence of pleural effusions. I agreed with most correspondents who listed cancer as their main differential diagnosis and therefore wanted computed tomography. I liked Lennox's advice not to be “reluctant to change the provisional diagnosis” and his conclusion “let's be optimistic.”

So this common presentation took a few diagnostic steps to determine causation. My final comment? Better access to a wider range of diagnostic tests is needed in the NHS. Although structured clinical decision making should still limit our expectation of needing tests, when that need is determined, access to tests should be comprehensive and rapid.