The Death of the Physical Exam

I recently saw a young man who had experienced a short run of atrial fibrillation (an arrhythmia) during an elective outpatient surgical procedure. His primary care doctor wanted help with the arrhythmia and so sent him to me for a consult.

He had no significant medical history, and he was active and completely asymptomatic.

I took a detailed history and performed a physical exam. On my exam, I heard a diastolic heart murmur very suggestive of aortic regurgitation. It was not subtle. I asked him if he had ever been told he had a heart murmur. He said he did not know what a heart murmur was.

I sent him for an echocardiogram and the echo showed that he has a bicuspid aortic valve, severe aortic regurgitation, and an ascending aortic aneurysm.  The normal valve has three cusps, but some people are born with two of the three fused together. This is a genetic condition that can lead to degradation of the function of the valve which can cause it to be incompetent and leak. Leaky valves can lead to failure of the heart muscle. Some people with bicuspid valves also have a ballooning of the aorta just after the valve (an aneurysm). This is has a high likelihood of rupturing when it gets to be too big. Rupture is almost always fatal.

He needs surgery urgently. If he gets surgery, he should do very well. His heart muscle is still strong, and replacing his aortic root will prevent it from rupturing.

This is a young man in his early 30’s. I can’t begin to estimate the number of people who had listened to his heart before I did. At the very least, the anesthesiologist and his primary doctor had just listened in the past few weeks.

If he had not had elective surgery, he would likely have not been found to have atrial fibrillation.

If he had not been found to have AF, he would not have been sent to me. If he had not been sent to me, he would not have known that he has a life-threatening medical condition that needs surgery urgently. In that case, he would likely have just died suddenly.

This would have been entirely preventable. Either we need to get better at teaching the physical exam again, or we need to find a viable alternative.


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