Friday, 23 January 2009


The other week I saw a man in his mid-twenties who had recently arrived in this country. Before he left home his doctor there had started him on three different tablets for his blood pressure. He had been reluctant to take his tablets and had in fact stopped them when he saw our practice nurse for his registration check. We still offer this check to all patients joining our list. We used to be paid a small amount for doing it, but although we no longer get any money it still seems a useful thing to do. The nurse will take a basic history, discuss health promotion and check routine things like weight, blood pressure and urinalysis which give us some baseline measurements. With women she can confirm details of smears, and with children she can ensure immunisations are up to date.

Nurse had suggested that he restart his medication, and when he saw me his blood pressure was completely normal. He had no signs of chronically raised blood pressure in his retinal vessels and there was no protein in his urine. But I got terribly excited because I thought I could hear a “bruit” in his left renal artery. This is a "whooshing" sound over the artery which can indicate narrowing (“stenosis”), and this can be a cause of high blood pressure. It is also extremely rare, and a GP would only expect to see one case in his professional lifetime. But since “idiopathic” hypertension (with no known cause) is also very rare in people in their twenties, renal artery stenosis is more likely in such patients. I have already made one diagnosis of renal artery stenosis, which really made my day at the time. The hospital doctor couldn't hear the bruit but referred for investigation because I had heard it, and my hearing was accurate on that occasion. I was rather hoping that I had found another.

But I thought that I ought to start from scratch before referring him to the hospital. So I asked him to stop taking his medication again, and arranged some blood tests and an ECG. These were all normal, and when I saw him again today so was his blood pressure! Moreover, on listening to his abdomen again I realised that what I had thought might be a bruit from his left renal artery was really just normal heart sounds transmitted from the chest. I was a bit disappointed, but of course it's much better for him and so I am pleased. One diagnosis of renal artery stenosis is quite enough for one career. :-)

I am going to see him again in a month just to make sure that his blood pressure continues to behave itself, and he will buy himself a BP monitor and take some home readings in the meantime.


Jellyhead said...

This has happened to me a few times, too - thought I'd made a rare diagnosis and almost felt disappointed when it was not what I'd thought. As you say, though - it's much better for your patient if he is actually fine!

Anonymous said...

Hi hi; I recognize this too... The opposite is that you are secretely glad when you do make a rare and difficult diagnosis... even when that's not-so-good-news for the patient.