Welcome to the 26th WONCA Europe Virtual Conference Programme Scheduling

Abstract Body

Background and purpose

Paroxysmal hematoma of the fingers refers to a clinical picture where patients suffer sudden episodes of pain and edema of one or more fingers with subsequent appearance of predominantly hematomas in the palmar region of the proximal phalanges. It is a rare and benign process of unknown etiology. The first symptoms are severe pain, tingling and itching prior to the change in skin color. There is self-limited subdermal bleeding that disappears in the following days. The diagnosis is clinical with normal complementary tests. The main differential diagnosis is with acute ischemic processes because they have a similar presentation. Its evolution is benign and resolves without leaving sequel.

Methods and results

A 64-year-old female patient,without allergies, non-smoker, with a history of hypertension, dyslipidemia and anxiety. Current treatment, alprazolam 0.25mg/8 hours, bisoprolol 5mg/24 hours, hydrosalurethyl 50mg/24 hours, simvastatin 20mg/24 hours.

Consulting for sudden and very intense pain with subsequent appearance of hematoma in the palmar region of the fourth finger of the right hand. At the time of the examination, she had no pain with correct mobility,we observed hematoma at proximal phalanx and the middle of the fourth finger. Good distal capillary filling, radial and ulnar pulse present. Analytical non-coagulation alterations rule out autoimmune diseases. Arterial echo Doppler of the upper limb without alterations. Evolutionary control in 5 days shows process in resolution.

Conclusion

Although it´s a rare entity to see in the consultory,it´s necessary for the general practitioner to be aware of it in order to be able to advise the patient correctly and avoid unnecessary complementary studies.

Abstract Body

Background and purpose

Abdominal aortic aneurysm (AAA) is the pathologic dilation of the abdominal aorta and is often asymptomatic but has high susceptibility to rupture.

Reported mortality rates for patients with a ruptured AAA are considerably higher than those for patients undergoing elective AAA repair, so it is imperative to diagnose AAA before rupture.

Major risk factors for AAA are age older than 65 years, male gender, smoking habits and family history.

Methods

A 66-year-old man presented to the health care center with a few months history of abdominal pain located in the periumbilical region. He had medical history of hypertension, hyperlipidemia, peripheral arterial disease and a 43 pack-year history of tobacco use.

Results of his physical examination included a soft mild distended abdomen with generalized tympanic sounds, except for the periumbilical region that presented with muffled sounds. Palpation was painless, no masses or organomegalies were palpated, although it seemed to present a “thickening” of the periumbilical region.

Results

The abdominal ultrasound revealed an aneurysmatic dilation of the juxtarenal abdominal aorta with an extension of 83mm and a diameter of 55 mm, showing a parietal thrombus with approximately 29mm.

The patient was proposed for surgery that underwent without any complications.

Conclusions

Since AAA are typically asymptomatic, screening with ultrasound is extremely important in the early detection of unknown AAA, specially in the elderly and those with risk factors.

Bearing this in mind, the adoption of screening programs plays an essential role in providing a beneficial outcome for these patients.

Abstract Body

BACKGROUND AND PURPOSE:

Dilated cardiomyopathy (DCM) is a clinical diagnosis characterised by left ventricular or biventricular dilation and impaired contraction that isn’t explained by abnormal loading conditions (e.g., hypertension and valvular heart disease) or coronary artery disease. The heterogeneous aetiology includes both genetical and non genetical causes (such as viral infections, drugs/toxins/allergens exposure and systemic endocrine or autoimmune diseases); and clinical presentation of DCM make a correct and timely diagnosis challenging. By presenting this case report we aim to highlight the importance of primary prevention and our role as general practitioners/family doctors.

METHODS:

Review of a patient clinical record through ECAP (electronic health record)

RESULTS:

44–year-old man without personal pathological antecedents, homeless, smoker, with an alcohol daily consumption of 9 Standard Drink Units. He was attended at the emergency ward of our primary health care centre due to malaise, oedema, dyspnoea, paroxysmal nocturnal dyspnoea and abdominal pain. Physical examination showed hypertension, bradypsychia, jaundice, ascites and signs of biventricular failure. EKG showed signs of left ventricular hypertrophy. He was referred to the hospital for further examination and treatment. Following supplementary exams, he was diagnosed with congestive heart failure due to enolic cardiomyopathy. After discharge he received regular check-ups both at the primary health care centre and hospital with an improvement of his condition, though later he didn’t retun.

CONCLUSIONS:

Alcohol and substance abuse is major public health issue. DCM and congestive heart failure are probable outcomes, both associated with high mortality/morbidity rates. As primary health care providers, primary prevention, early diagnosis/treatment and an holistic and longitudinal perspective are keywords for our job.

Abstract Body

Background

Carotid artery dissection is a cause of stroke, particularly in young adults, but may occur at any age. There seems to be a slightly higher incidence in males vs females. Common causes of arterial dissection include trauma or spontaneous events, with underlying predispositions in some cases. Most dissections occur spontaneously or after minor or trivial injury. Dissection most often results in ischemic stroke or transient ischemic attack, usually associated with local symptoms such as neck pain or headache, Horner syndrome, cranial and cervical neuropathies, and pulsatile tinnitus.

Methods

A 55-year-old male was admitted to an appointment in a health care center. The patient presented with temporal right headache for 6 days, blurred vision and photophobia in the right eye, dysarthria and tongue movement limitation to the right side. He denied cervical trauma, although he reported a chiropractic session 2 weeks before for cervical radiculopathy. He was referred to the emergency department and admitted to Neurology ward on suspicion of carotid artery dissection.

Results

The patient underwent Computed Tomography Angiography that showed carotid artery stenosis of 55%, probably due to a carotid dissection. These findings were then confirmed by MRI, which excluded ischemic stroke. He was discharged on antiplatelet therapy and was referred to speech therapy. To the present date, there was an overall improvement without symptoms recurrence.

Conclusions

The clinical diagnosis of carotid artery dissection can be challenging. It’s important for primary care physicians to be aware of this condition, since they are often the first sought by patients.

Abstract Body

Background and Purpose:

Peripheral neuropathy usually affects the extremities and the most frequent cause is diabetic peripheral neuropathy. Other causes include shingles (post-herpetic neuralgia), B12 deficiency, alcoholism, etc. Most neuropathic ulcerations occur on the lower extremities and affect prominent different areas of the feet such as the heel and metatarsal heads, or areas of high friction that are prone to callus formation.

Methods: Case report

Results:

An alcoholic 55 year-old male with lower-limb alcoholic neuropathy went to the primary care center on numerous occasions due to an ulcer on the right foot-sole. The patient was being treated with antibiotics, cleaning of the wound and the use of medical insole. However, the ulcer did not improve and evolved to produce intense pain and a strong smell. During the conservative treatment with diferent antibiotics and analgesia, the evolution was bad and the ulcer developed in osteomielitis.

The patient was referred to different departments (dermatology, traumatology, internal medicine) to obtain a proper diagnosis. After biopsies, computerized axial tomography and magnetic resonance, the patient was diagnosed of Neuropathic Ulcer. A surgical procedure together with a stronger antibiotic regime was required to close the ulcer, which has not relapsed until now.

Conclusion:

A neuropathic ulcer has a high probability to evolve to osteomyelitis if it is not properly treated. General practitioners must not underestimate the chance of a non-diabetic person to suffer from severe pathologies usually associated to diabetes, as these need a very early diagnosis and treatment to enable their survival and recovery.

Abstract Body

Background and purpose

Emergency cardiac problems arise suddenly and If not treated immediately, sudden cardiac arrest can lead to death. Survival rates are low in out-of-hospital cardiac arrests. Such cases sometimes refer to Family Health Centers (FHCs).

Case

On 12.02.2021 at lunch-time, a patient's relative came to FHC and said that his father couldn’t breathe at home and was standing still on the ground. The patient's home was reached at once.

The patient was 62 years old, male, had no known illness, didn’t use drugs, was a heavy smoker, had chest pain but didn’t consult a physician. Cardio-pulmonary resuscitation (CPR) was performed (at 12:53) because the pulse couldn’t be found. The ambulance team arrived at the 5^th minute’s of the CPR.

Tracheal intubation was performed. 1 mg adrenaline IV pulse and 0.9% NaCl solution was applied. The patient was asystole. At 13:12, the femoral pulse was palpated and the rhythm was found to be ventricular fibrillation and a 200 joule shock was applied with a defibrillator. The patient returned to sinus rhythm and was transferred to the emergency department. In coronary angiography, there was occlusion in coronary arteries. The patient, whose clinical condition is stable, continues to be treated in intensive care.

Discussion

Emergency health care is also included within the scope of primary health care services. The family physician has the responsibility of being ready for emergencies at all times, providing comprehensive care for all those need medical care and coordinating other healthcare personnel when necessary, acting within the framework of the core competencies of the family medicine discipline.

Abstract Body

Introduction: Vasospastic or Prinzmetal angina is characterized by episodes of rest angina associated with transitory ST segment elevation on ECG, that are caused by a focal or diffuse epicardial coronary artery spasm. Smoking is a major risk factor; other possible triggers are alcohol and drug consumption. The prognosis depends on the presence and extent of fixed atherosclerotic lesions. Patients with vasospastic angina and normal coronary arteries have in most cases good prognosis. The authors present one case of Vasospastic angina.

Case Report: A 54-year-old man smoking 20 cigarettes, with moderate alcohol consumption and dyslipidemia, reported recurrent episodes of syncope and mild chest pain at rest which spontaneously ceased after a few minutes. Of the diagnostic tests performed, ECG was normal, echocardiogram also normal, with good ventricular systolic function and cardiac stress test without symptoms and any ST-T alterations. Holter showed 5-minute duration periods of supra ST at night, without symptoms, compatible with Prinzmetal Angina. The patient was medicated with a calcium channel antagonist and a nitrate and underwent cardiac catheterization, which showed angiographically normal coronary arteries. He remained asymptomatic since then.

Conclusion: Vasospastic angina remains highly challenging to diagnose, but has important symptomatic and prognostic implications. Management includes cessation of smoking and pharmacologic therapy. When not associated with heart disease, long-term prognosis is good, particularly those receiving medical therapy, thus coronary vasospasm does not by itself result in a significant increase in mortality, although patients who present with syncope may be at greater risk.

Abstract Body

Peripheral arterial disease (PAD) affects about 3 to 10% of general population and 15 to 20% of individuals over 70 years (NORGREN, L. et al, 2007). PAD results in most cases of atherosclerotic obstruction of the arterial lumen.

Despite the fact that the lower limbs are the most common location, and for this reason are most frequently researched and diagnosed, it is important to be aware of other clinical manifestations of PAD. Subclavian artery stenosis, mainly on left side, occurs in about 2% of general population and in 15% of patients over the age of 70 (Shannon Caesar-Peterson 2020). Its diagnosis is essential to avoid the associated complications that range from limb claudication, to cerebral hypoperfusion and stroke.

Our case reports a 73-year-old man chronic smoker with a medical history of gastric ulcer and psoriasis, whose chief complaint was several episodes of hypotension, associated with daily dizziness, hyposthesia of the left upper limb and chest pain. After a careful cardiovascular examination, a blood pressure differential was detected between the upper limbs and the subsequent imaging study revealed the presence of left subclavian artery stenosis. The patient was subsequently referred to vascular surgery and was submitted to left subclavian artery stenting.

This case highlights a rare cause of hypotension so that subclavian artery stenosis is a diagnosis which family doctors have to be aware of.

Abstract Body

Background and purpose

Worldwide, Auricular Fibrillation (AF) is the most common sustained cardiac arrhythmia in adults, and it can present with similar symptoms as COVID-19, as dyspnea and fatigue.

Case Report

M., female, 81 y/o, requests an urgent appointment with her GP with complaints of dyspnea, fatigue and bilateral leg swelling for the last 2 weeks. She denies syncope, chest pain, dizziness, headache, fever, cough, myalgia, anosmia or dysgeusia. She lives alone and has had no contact with any other person on the last 3 weeks.

Past medical history: Congestive Heart Failure, Essential Arterial Hypertension, Dyslipidemia, Obesity (BMI 34 kg/m²), Depressive Disorder, Hypothyroidism, Bilateral total hip replacement.

Medications: Amlodipine/Olmesartan 5/20mg, Furosemide 40mg id, Bisoprolol 2.5mg id, Simvastatin 20mg id, Amitriptyline 25mg id, Levothyroxine 0.075mg id, Clebopride 0.5mg id. She denies smoking.

Clinical findings: awake, responsive, tachypneic, SpO2 94%, HR 109bpm, BP 94/72mmHg; irregular pulse; irregular rhythm on auscultation, no other heart murmurs; no abnormal lung sounds; bilateral and symmetric leg edema with positive Godet sign. No other abnormal findings on physical examination.

ECG: Atrial Fibrillation with Rapid Ventricular Response, HR 153bpm.

The patient was referred to the Emergency Department with the activation of the Pre-Hospital Medical Emergency Services. She was immediately admitted with the diagnosis of Decompensated Congestive Heart Failure and de novo Atrial Fibrillation.

Discussion

As we sail through this pandemic, we need to keep in mind that there are urgent diagnosis with respiratory symptoms other than COVID19. Excluding epidemiologic context of COVID19 infection is essential to not delay urgent care to these patients.