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ECG Quiz Question

Acute Dyspnea and a New Murmur in a Team Physician

John D. Cantwell, MD; David T. Watson, MD; William A. Blincoe, MD; James R. Kauten, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 5 - MAY 98


A 61-year-old physician for a professional sports team experienced transient palpitations and dyspnea while playing in an over-50 basketball scrimmage. He had been physically active for many years, had no known cardiopulmonary disorders, and had never been told of a heart murmur. He had not been febrile, nor had he experienced any chest pain. There was no history of recent dental work.

Over the next 2 to 3 weeks his dyspnea occurred at lower levels of exertion and was accompanied by ankle edema and a nonproductive cough. An upper-respiratory infection was suspected, and a physician placed him on antibiotics, which brought no apparent improvement. The patient auscultated his own heart and detected a decrescendo diastolic murmur, which prompted him to seek cardiologic assessment.

His medical history was unremarkable except for diagnosed diverticulosis and an allergy to topical neomycin.

On physical examination his blood pressure was 120/46 mm Hg, and his pulse was 68 per minute and regular. He was afebrile. His neck veins were not distended, and carotid pulsations were not exaggerated. The thyroid gland was of normal size. Auscultation revealed bibasilar rales in his chest and a grade 2 decrescendo diastolic murmur heard best at the right second intercostal space. No S3 or S4 diastolic gallop sounds were present. His abdomen and extremities were normal. There were no Marfan syndrome features.

Routine laboratory tests showed a hemoglobin of 14 g/dL and white blood cell count of 9,700/microliter with a normal differential. His sedimentation rate was normal at 6. A biochemical profile was normal, and his serum cholesterol was 114 mg/dL, similar to previous measurements. Multiple blood cultures were negative.

[FIGURE 1]

His chest x-ray is shown in figure 1 and his chest resting electrocardiogram (ECG) in figure 2.

[FIGURE 2]

What does the new murmur imply?

What is your differential diagnosis, and what additional studies would you obtain?

Dr Cantwell and Dr Blincoe are cardiologists at Cardiology of Georgia, PC, and Dr Cantwell is a clinical professor of medicine at Morehouse School of Medicine, both in Atlanta. Dr Watson is an internist at the Piedmont Physicians Group in Atlanta. Dr Kauten is a cardiothoracic surgeon at Peachtree Cardiovascular and Thoracic Surgeons and chairman of cardiothoracic surgery at Piedmont Hospital, both in Atlanta. Dr Cantwell is an editorial board member of The Physician and Sportsmedicine. Address correspondence to John D. Cantwell, MD, Cardiology of Georgia, PC, 95 Collier Rd NW, Suite 2075, Atlanta, GA 30309.


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