Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

A Commonly Uncommon Patient

The Rolling Stones in concert at the British Summer Time Festival in Hyde Park, July 6, 2013. Wikimedia, Public Domain.


Asking colleagues for help and re-reviewing data are essential in identifying clues to an accurate diagnosis.

Mr. G was a 65-year old-retired Coastguardsman who came to my clinic “wanting to move like Jagger.” He had prior coronary artery bypass surgery in 2010 for asymptomatic multivessel coronary artery disease. Over the past several years, he experienced a gradual decline in his exercise tolerance.


Mr. G underwent an extensive evaluation including bloodwork to exclude anemia and hypothyroidism, pulmonary function testing and chest imaging, and cardiovascular testing. His testing initially suggested the presence of moderate to severe mitral regurgitation, and I referred him to a colleague for consideration of percutaneous mitral valve repair. His mitral valve was further assessed and believed not to be sufficiently diseased to warrant repair. In retrospect, he had scattered clues throughout his prior testing that suggested the diagnosis of constrictive pericarditis, which could certainly explain his ongoing symptoms.


He underwent pericardial stripping and he is now hopeful that he will be able to move like Jagger.


Lessons learned from caring for Mr. G:


1. Constrictive pericarditis is a commonly discussed and widely known condition, but patients with the actual diagnosis are rarely seen by physicians (including cardiologists).


2. It is always OK to ask for help. When Mr. G was not feeling better despite numerous tests and treatment changes, I asked a colleague for help, which ultimately helped the patient.


3. Reviewing and re-reviewing data was essential in identifying clues to Mr. G’s diagnosis. One cannot possibly recall all patient data at all times.


4. When common diagnoses are ruled out, it is important to consider less common ones (like constrictive pericarditis), even if you have never encountered someone with this diagnosis before.