A 44 year old African American presented to the clinic with cough and congestion.
She described her congestion as in her head, with stuffy, runny nose and constant sniffling. Her throat was irritated, and she had a dry cough that was bothering her. This had been going on for 2 days. She said she also had congestion in her chest and the mucous made it hard to breathe sometimes. She had not tried any OTC meds for this condition. She took medicines for diabetes and high blood pressure: lisinopril and metformin. No other issues such as chest pains, dizziness, fainting spells, throwing up, diarrhea, urination problems. Her vital signs were Temp 97.7 F, BP 150/90, pulse 37, resps 12. The patient was somewhat obese. Her lung sounds were clear on exam. Her husband was at the clinic for the same symptoms.
WHAT IS THE PRIMARY DIAGNOSIS?
Another routine URI, but who cares because OMG DID YOU SEE THAT PULSE?!?
Vital signs are called that because they are kind of vital. Other aspects of the physical exam can be ambiguous or tricky; not so with the hard, basic numbers of a patient’s vitals. It doesn’t matter how banal the patient’s chief complaint is — a physician must check these numbers for every single patient, every single time.
Resting pulse rates typically range from 60 to 100 for adults without cardiac conditions or other complicating factors such as a fever or anxiety. Younger atheletes can push this into the 50s or even 40s. According to National Geographic, five-time Tour de France winner Miguel Indurain had a resting heart rate of just 28!
But, Tour de France cyclists are not people I see in my clinic. On rare occasions, I do see atheletes with pulses in the 50s, but that’s as low as I’ve seen for anyone who wasn’t near-death. A pulse of 37 in a middle-aged, on-the-heavy-side, diabetic woman simply does not compute. The pulse was so low that our automatic blood pressure cuff could not get a reading — I had to do it manually.
I checked her records, and she had a similar rate a year before. She said she saw a cardiologist who checked everything out and declared her heart healthy. While she was on meds for her pressure, she was not on any beta blocker that would directly slow her heart down. She had no heart illness to explain it. It’s simply who she is.
Such idiopathic bradycardia is probably genetic, and actually indicates an unusually healthy ticker. Had my patient decided to become a professional athelete in her younger years, she may have had a real shot at the Olympics. Having unusually beneficial genes for athletics is not unprecedented, as one tribe of Kenyans could probably tell you. Bad genes and horrifying genetic diseases may get all the ink in med-school textbooks, but nigh-superhuman genes are even more fascinating, at least to me.
The remarkable nature of the human body continues to astound me, no matter how cynical of an urgent-care doc I may be.