Musings of a master clinician: Interesting students’ clinicopathological conference at Postgraduate Institute of Medical Education and Research, Chandigarh, on one of the Mondays in 1977

I am Dr Surendra Kumar Sharma; I had worked at the All India Institute of Medical Sciences (AIIMS), New Delhi, since 1979 till December 2016 in the Department of Internal Medicine as Chair of the Department of Internal Medicine and Chief of Pulmonary, Critical Care and Sleep Medicine, in-charge of Anti-Retroviral Treatment Centre and Revised National TB Control Programme (RNTCP, now called National TB Elimination Programme, NTEP), DOTS Centre at AIIMS, New Delhi. On 6th August 2024, I met Professor B. Soma Raju (Figure 1) in his office at the Asian Institute of Gastroenterology Hospital in Hyderabad, Telangana State. He was my senior and doing DM in Cardiology in 1977 at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, and I was an MD student. We stayed in the same hostel and floor (third floor) in Kairon Block of PGIMER, Chandigarh. His hostel room was third from my room. He was a great source of inspiration and taught the basics of internal medicine, especially the explanation of various physical findings. These things he did in evening rounds and classes which were held till late night. While we were catching up with the time that had elapsed, I had remembered an incident related to the students’ clinicopathological conference (CPC) and we had reminisced the discipline and rigour with which CPCs were held at PGIMER, Chandigarh, in those days.Figure 1: Professor S. K. Sharma (left) with Professor B. Soma Raju (right)For the benefit of the present-day younger generation of postgraduate students, I am narrating my own experience of one of the ‘Students’ CPCs which I had discussed while doing my junior residency programme in the Department of Internal Medicine at PGIMER, Chandigarh. This was a CPC from an era, where, apart from electrocardiogram (ECG), and chest radiograph, none of the investigations, such as, two-dimensional echocardiography, Doppler echocardiography, computed tomography (CT), cardiac magnetic resonance imaging (MRI), brain natriuretic peptide (BNP), N-terminal pro-brain natriuretic peptide (NT-ProBNP) were available. On one of the weekends, I was handed over a file for the discussion of the case of a 32-year-old female who had recently died at PGIMER, Chandigarh. I was told that I am getting a simple case of rheumatic heart disease (RHD) with tricuspid regurgitation (TR), mitral regurgitation (MR) and congestive cardiac failure (CCF). While going through the case history of this patient, I was struck by the chief complaint of classical angina pectoris that had occurred in this young female – left-sided chest pain occurring after walking a distance of few yards and compelling her to discontinue walking. This had been happening for the past several months. She complained of exertional as well as paroxysmal nocturnal dyspnoea. She also complained of discrete episodes of palpitation. The patient complained of pedal oedema and discomfort in the right upper quadrant of the abdomen. On examination, the patient had raised jugular venous pressure with ‘v-y’ venous wave pattern, tender hepatomegaly and bilateral pitting pedal oedema. The clinical features on auscultation were compatible with mitral and tricuspid valvular regurgitation. There was no mention of the loud P2 component of the second heart sound in the case file. Auscultation of the chest revealed fine-to-medium crepitations on both sides. The chest skiagram revealed striking cardiomegaly with an empty pulmonary bay and prominent upper lobe veins and Kerley B lines. The electrocardiogram revealed left axis deviation, QS pattern in the inferior wall leads and upright R waves in V1 with upright T waves. During those days, computed tomography of the chest and two-dimensional or M-mode echocardiography were not available. Diagnosis of the admitting medical unit was RHD, MR, TR and CCF. Cardiology consultation was sent; the consultant and his senior resident from the cardiology department endorsed the diagnosis of the admitting unit and advised to continue the treatment for CCF. The patient did not show any improvement and died. I read the case file carefully again and again and thought that in the presence of classical angina-like chest pain, why a diagnosis of coronary artery disease (CAD) or ischaemic heart disease (IHD) was not considered in the differential diagnosis. This prompted me to consult my seniors. We residents had uniform choice of consulting the most easily accessible and favourite senior resident of the Department of Cardiology, Dr B. Soma Raju. I was lucky enough to share the same floor of the hostel in the Kairon Block at PGIMER, Chandigarh. His hostel room was third from my room. I discussed this case at length with Dr Raju. After seeing her chest radiograph, he said that an empty pulmonary bay suggests that the TR is not due to pulmonary artery hypertension (PAH). Therefore, RHD is less likely diagnosis in this case. He gave me his personal copy of the Hurst’s Textbook of Cardiology and advised me to read carefully about the anatomy of cardiac chambers including the mitral valve apparatus, its leaflets and chordae tendineae etc., and clinical features of papillary muscle dysfunction and characteristics of murmurs of rheumatic and non-rheumatic MR and TR. He also advised to read carefully venous thromboembolism as the second differential diagnosis and to discuss this case again with him sometimes during the ongoing week. We discussed again and again and jokingly Dr Somaraju had said that this is the most difficult case for an MD junior resident. I prepared cards for the epidiascope projection and showed him all the presentation cards. Dr Somaraju asked me whether I had written the main diagnosis as CAD/IHD that resulted in inferior wall infarction and extension to the posterior wall. It’s going to make your bosses unhappy as they will simply say that it’s a wrong diagnosis! On the D-day, I was a bit nervous and started with the saying that I may be excused for the blunder I am going to commit as I am still a student trying to learn medicine from my Gurus. I made the final diagnosis of CAD, old infarction of inferior and posterior walls with ischaemic cardiomyopathy, MR, TR and CCF and no PAH. After my clinical discussion, the admitting medical unit and the faculty of the cardiology department said I was talking something non-sense which is not possible. The patient discussed was a young female patient and CAD is very rare at this young age group, especially in females! They had not considered this possibility at all. Probably, the TR was organic TR due to RHD (not functional TR)! The treating medical unit stated that they had felt that this patient had RHD but not CAD. I stood up in defence stating that the pulmonary bay on the chest X-ray was not prominent which is highly suggestive of the absence of significant PAH. The consensus after my clinical discussion was that ‘the student has missed RHD diagnosis’. Subsequently, the 2nd-year MD student from the department of pathology started his discussion. Pathology findings included increased weight of the heart. He showed carefully dissected coronary arteries with complete blockade of the lumen of coronary arteries. In addition, there was evidence of old infarction of the posterior and inferior walls of the heart and at places prominent areas of cardiac fibrosis. Once the pathology resident finished his discussion and sat on the chair, the student chairperson opened the case for discussion. Iremember that there was a pin drop silence in the lecture theatre for a couple of minutes. Faculty from the departments of internal medicine and cardiology faculty staff said that this was indeed a difficult case for a PG junior resident and it was an apt case for the staff CPC. No one congratulated me for a correct diagnosis. After the CPC was over and the audience was dispersing, I heard murmurs and rumbles stating that ‘this resident knew the diagnosis’. I felt very sad and was almost in tears. In the evening, I went to Dr Soma Raju’s room and told him that I didn’t deserve these comments. He consoled me saying that ‘this world is like this; if you make a wrong diagnosis then they will say that this resident is an idiot and if you hit the correct diagnosis then they say he knew the diagnosis’. We always looked up to him for encouragement and mature advice. Memory of this case looms large in my brain and I’m thankful to Dr Raju for his constant encouragement and I always admire him for his affection and honest advice. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.