A Country Doctor Writes:

Jack Frommer has been my patient since last fall. He has high blood pressure and high cholesterol and he had a small heart attack six years ago.

Jack hates to take pills, and that was one of our topics when I first met him. He needed some changes in his regimen, based on his history, lab work and physical exam.

We had a lot of ground to cover in that first visit, but I don’t remember feeling particularly rushed. Other than his blood pressure, his cardiovascular exam was normal. I re-read my notes the other day. His heart sounded regular without murmurs, his neck veins weren’t engorged, his carotid arteries didn’t have bruits, and the pulses at his ankles were good and strong. I remember him pointing out as I listened to his neck that nobody had done that before.

His three-month follow-up was encouraging. His cholesterol had dropped below his target level with the new medication I had prescribed, and his blood pressure was almost normal. I spent some extra time on his smoking and the importance of taking aspirin.

I didn’t do much of an exam that day because it was a brief visit with a lot of numbers to talk about.

At his six-month follow-up all the numbers looked good. We talked about the 3-4 cigarettes he was still smoking. I listened to his lungs and repeated his cardiovascular exam.

Suddenly, there it was: A loud, harsh scraping bruit in the lower portion of his right carotid artery.

An ultrasound suggested a stenosis greater than 80% and an MRA clinched the deal. Within weeks, Jack had surgery to remove the buildup in his neck artery.

In follow-up he and his wife showered me with praise for saving him from a stroke by listening and noticing the abnormal sound in his carotid artery.

I felt humble. I had not heard it the first time I listened.

Doris Delaney came back to see me a week after her semi-urgent cardiac catheterization. I already knew her coronary arteries were normal. The cardiologist had called from the cath lab immediately after the procedure to let me know. His words on the phone and in his discharge summary were that she had “noncardiac chest pain”.

Doris was obviously not relieved. She comes from a family with a dark cloud of cardiac history hanging over it and she had a markedly abnormal stress-EKG. She was still having crushing, squeezing chest pressure with exertion.

Could this really be esophageal spasm, nerves or chest wall pain, I wondered.

Her symptoms didn’t really fit the definition of vasospastic angina, which tends to occur more at night or with emotional stress than with physical exercise. Women do tend to develop blockages in smaller arteries than men, but in Doris’ case, the cardiologist was adamant that it was not her heart.

I have asked a couple of cardiologists what their thoughts are on patients with classic angina pectoris, positive stress-EKG’s and normal nuclear scans. Everyone has told me the nuclear scan overrides the EKG findings, and no one argues with a catheterization report.

That answer intuitively makes me uncomfortable. The electrical recording of the EKG can pick up changes in potassium levels and inflammation like pericarditis. Why might it not pick up small changes in oxygen supply to parts of the heart muscle that other technologies can’t?

But Doris had “essentially clean coronary arteries”. Why could I not leave it at that?

I prescribed a calcium channel blocker to tighten her blood pressure control, also hoping that it would help what I thought might be some coronary spasm. I made sure she was still taking her new cholesterol medication and her acid reflux pills. We agreed on a follow-up with blood work beforehand within a few weeks.

Less than a week later I saw her name in my schedule again. After her name were the words “still having chest pain”.

My heart sank. I sat down at the computer, logged on to my online database and did a quick search.

There, suddenly, was exactly what I had felt in my own heart was behind Doris Delaney’s chest pain. How many more patients had I seen with the same condition? How many patients were leaving the cath lab at Cityside Hospital without finding out that this is what they have?

I sank deeper into my chair as I kept reading.

Cardiac Syndrome X, not to be confused with the Metabolic Syndrome (previously called Syndrome X), is twice as common in women as in men. Patients have typical, exercise-induced chest pain, positive stress-EKG’s and minimal coronary artery abnormalities on catheterization. They sometimes do worse on the medications we often use for vasospastic angina, do better on beta blockers, tend to have only a moderately increased risk of myocardial infarction and sometimes get better on their own over time.

Searching elsewhere I found that even the New England Journal of Medicine has published a couple of articles on Cardiac Syndrome X in the past decade. I don’t remember seeing them before. I wish I had.

I clicked on “Print”, gathered my thoughts and papers, and knocked on Doris’ exam room door.

“I’ve been thinking a lot about your chest pain, and I’ve found some things I’d like to show you”, I began.

Bibi and Dwight, both in their mid-sixties, always move as a unit. They have been married for forty years. Early on, they were athletic and adventurous, but over the past five or six years Dwight has developed macular degeneration and a fairly severe case of arthritis.

I have seen him once a year for a physical and usually no more. At his last two physicals, Bibi brought up her concern that Dwight was tired. She has always been present for his visits, even before his eyesight started to fail him. He always downplayed his fatigue and blamed it on his age.

This time I focused my exam on different causes for fatigue and ordered several blood tests. Bibi seemed pleased, but Dwight seemed distant and unengaged. I suspected he might be depressed about his arthritis and near blindness. We agreed to have a follow-up to go over the test results.

The only remarkable thing about his results was a borderline low thyroid function, which usually doesn’t cause any symptoms at that level.

As it happened, Bibi had her own appointment with one of my colleagues at the same time as Dwight came back to go over his test results.

After greeting him, I started:

“Well, Dwight, all your blood work looks fine…”

“I was sure it would”, he interrupted. “Listen, Doc, I know why I’m tired”, he said with a tone of frustration in his voice.

“I love Bibi, but she’s not like you or me”, he began whispering. “From the crack of dawn till way past anybody’s normal bedtime, we have to work. In the spring and summer it’s the gardens. We grow more vegetables than we could possibly eat. In the fall it’s the raking and the firewood. We are three years ahead on wood now. In the winter we dust and reorganize all her books and knickknacks. We never relax; we never sit down and talk. She always has to be busy. She’s wearing me out, Doc!”

He raised his arms in a gesture of exasperation.

“Help me, Doc!”

Just then, there was a knock on the exam room door. Autumn, my nurse, peeked in and said:

“I’ve got Bibi here, are you ready for her to join you?”

I glanced at Dwight. His eyes sank to the floor as he nodded.

“So, how is my boy?” Bibi said as she sat down next to Dwight while I quickly gathered my thoughts.

“Well, it’s nothing serious”, I said, “but Dwight has subclinical hypothyroidism, which is due to an autoimmune process in the thyroid. Some people get quite tired with that, more than you might expect from the thyroid numbers alone. Coupled with his arthritis, I expect Dwight to be more tired both physically and mentally than he was a few years ago.”

Both Bibi and Dwight had their eyes on me as I came to my concluding statement:

“I think with more rest built into his day, he should be good for many more years.”

As we said good-bye, his knotted hand squeezed mine quite hard for a person with arthritis.

Gwen and Dan Olsen were a handsome couple with a stunning blonde eight-year-old daughter, Trina. They had just moved to the town where I did my residency and over the course of their first six months there I saw all three of them for routine health care needs.

One day Gwen came in for nausea. She didn’t look well and I could see in her facial expression that something was dreadfully wrong. Thinking unplanned pregnancy and morning sickness, I glanced at her problem list, where her husband’s vasectomy was listed, in my own handwriting, as her method of contraception.

“I’m pregnant”, she burst out, tears suddenly streaming down her cheeks. I sat quietly for a while. She didn’t say anything.

“Dan had a …”, I started.

“He’s not the father”, Gwen said.

Wiping her tears she described how she had gone back to her parents for a visit, run into an old boyfriend and found herself doing the unthinkable.

“Does Dan know?” I asked.

She nodded.

“What do you want to do?” I didn’t say the A-word, but she understood.

“We’ve talked it over and we’re going through with the pregnancy as if it were Dan’s baby”, she began. “He’s promised me he will love us both just as much as if he were the father. We’ll just tell people the vasectomy must have failed.”

“Those things happen”, I said.

“Will you be my doctor for the pregnancy?” she asked.

“Of course”, I nodded.

“And please don’t put anything in my medical record about it not being Dan’s.”

“Of course”, I reassured her.

That fall I delivered a beautiful baby boy to two of the nicest, proudest parents I know. I was able to see him, his parents and his sister through two years of well baby visits, shots and minor childhood illnesses during the last two years of my residency.

Several years later I happened to run into the four Olsens again. Little Brad looked just like his mother.

Today I read in a journal that a large percentage of patients won’t tell their doctor sensitive information if they believe their information might be shared electronically with other doctors, hospitals or insurance companies.

Some things are better left off the record.