A Country Doctor Writes:

Just in the past few months I have had three patients with crippling chest pain brought on by exercise who were dismissed as having noncardiac chest pain. All three are now essentially symptom-free on isosorbide and metoprolol – common antianginals. I may not know exactly how this treatment works, but I am passionate about providing for my patients the common medications we know work. Even a simple country doctor can do that.

Once upon a time there was only one common kind of angina and only one kind of heart failure. Now we know there are two kinds of each. For some reason doctors are all excited about the new epidemic of heart failure with preserved ejection fraction, but skeptical and uninterested in angina with normal coronaries. Both of these more recently discovered diseases turned the old definitions upside down. Doctors of my generation (and younger) have had to unlearn what they taught us in medical school. Many are still bucking.

Angina pectoris is a syndrome, a group of clinical signs and symptoms with several possible causes. When I went to school we talked of blocked coronary arteries or a rare form of angina occurring during sleep and caused by spasm, Prinzmetal‘s angina. We now know that many people, perhaps half of all angina patients, have normal coronaries as far as we can see them on catheterization but poorly functioning smaller blood vessels rather than pure spasm. This type is triggered by exertion, just like angina caused by major blockages.

Heart failure is also a syndrome. For the longest time it was believed that the problem was that the heart didn’t push the blood out well enough with each beat. Only relatively recently did it become obvious that about half of all heart failure patients have poor relaxation of the heart. We have been measuring what percentage of the blood is pumped out with each heart beat. That number should be greater than 55%. But if there is less than the normal amount of blood in the heart and you pump out only half of that, you don’t get enough pumping done for things to work.

Neither angina nor heart failure are strictly disorders of a mechanical system of plumbing. These days the term neuroendocrine pops up everywhere in the literature. Our arteries, big and small, and our heart muscles are not static but constantly changing and adapting. And our understanding of how this all works is still in the early stages.

Maybe we should trust our clinical assessment more often and not look blindly at the results of imperfect tests like Lexiscans, crude angiographies and blurry echocardiographies: If it walks like a duck and talks like a duck, maybe it really is a duck?

Ruth grew up in Alabama and ended up in northern Maine last year. We still don’t have her medical records, but she says she was diagnosed with Crohn’s disease when she was a teenager. She has had six months of constant abdominal pain that gets worse when she eats. She seldom has diarrhea but sometimes feels constipated. She often has dry heaves and sometimes vomits.

Her bloodwork is normal and the CT scan that was done in our emergency room had only mild signs of thickened wall of her colon. Her upper and lower endoscopes had very modest abnormalities with nonspecific findings on biopsies.

She has seen a gastroenterologist downstate and is waiting to have an MRI of her small intestine.

Meanwhile, her constant abdominal pain is keeping her from holding down her new job. Hydrocodone has helped her, but that was a stopgap measure from one of her emergency room visits. Now the hospital doctors have labeled her a drug seeker.

As I listened to her story and watched her healthy appearance I began to wonder.

“Has your weight changed during all of this?” I asked.

“Not really.”

“And you have no blood or mucous in your stool?”

“No.”

“And you’re in pain every single day?”

“Just about.”

“And this started when you left Alabama? Was that a stressful move, a stressful time?”

“It was huge. And I’m still stressed out. I mean I can’t work and I’m not making any money. Does that matter?”

“I don’t know, I’m just looking for clues…”

I went over what lab tests had been done. Her inflammatory markers were only slightly elevated.

I had asked her to avoid milk and gluten containing foods when I first met her. She told me that made no difference.

The only symptom she has, really, is constant pain, I thought to myself. What if this is functional, an upregulation of pain signaling – the intestinal equivalent of fibromyalgia?

I have been vaguely aware of this condition, this scenario, but have no experience treating it. A quick search suggests the only treatment options are psychological and lifestyle interventions.

If this is neuropathic, would medications like amitriptyline or gabapentin or duloxetine work? Could they replace her hydrocodone?

She was willing to try.

A few days later she told me her nights are pain free on 10 mg of amitriptyline. But she’s too tired to take that medication during the day.

So, while the downstate gastroenterologists pursue their testing for where there might be physical disease pockets, I am looking in a different direction. They aren’t ready to do that yet and they may never be. Functional conditions receive little attention in medically underserved areas.

A Gut Feeling: Could This Case Really Be That Simple?

Ned is about my age. He came to see me about a year ago with swelling of one leg.

A few weeks after a steroid injection into his right hip, he noticed a gradual swelling of that leg. The hip felt fine. And Ned felt fine in general.

I examined him carefully and ordered what I think of as the usual tests when one leg is swollen and the other one isn’t.

Routine bloodwork and cardiac exam, venous Doppler of his leg, CT scan of his abdomen and pelvis were all normal. The orthopedic folks ordered an MRI of his swollen thigh. This showed the swelling of lymphedema but nothing else.

He got a compression stocking and carried on with his usual work and leisure activities.

Last month he got another steroid injection to the hip. A few weeks later, his lymphedema was almost gone.

I have not found anything like it in my search for answers. Has anyone else seen or heard about transient unilateral lymphedema, related to steroid injection or not?

One more instance of me confessing to my patient:

“I just don’t know.”

In some practices, patients with seemingly simple problems are scheduled to be seen by a nurse or medical assistant. Sometimes they can even just drop off a urine sample in case of a suspected urinary tract infection.

This is a dangerous trap. What if the patient rarely gets urinary infections, has back pain and assumes it is a UTI instead of a kidney stone or shingles on their back just where one kidney is located; what if they have lower abdominal pain from an ovarian cyst or an ectopic pregnancy?

Another dangerous type of “nurse visit” is when patients focus on one symptom or parameter, thinking for example that as long as their blood pressure is okay, their vague chest pressure with sweating and shortness of breath isn’t anything serious. It’s one thing if I want a couple of blood pressure checks by my nurse, but a whole different thing when it is the patient’s idea, assumption or self diagnosis.

In many cases, a telephone call with the provider or a triage nurse can be safer and more diagnostic than starting with a nurse visit. Because the symptom history is usually more important when making a diagnosis. And nurse visits tend to be skimpy when it comes to the clinical history, even though the provider assumes responsibility for the diagnosis and treatment of a patient they didn’t talk to or examine.

Seemingly simple things can sometimes be disasters waiting to happen. Nurse visits are not billable, only the dipstick urine test is in my first example. But the malpractice payout could be bigger than for a missed diagnosis made by a thorough clinician in good faith – if there was little clinical history and no physical exam done, not even eye contact between patient and treating physician.

Consider this analogy: How much less is a meal at the takeout window than inside the restaurant? The cost is usually the same and it certainly isn’t free.

A Happy Meal is a Happy Meal, no matter where or how you receive it. Diagnosis and treatment are not defined by their setting or visit charge.

Our receptionist asked: “Do you want your 10 o’clock to reschedule? He has a runny nose, a cough and muscle aches”. He failed some of the Covid screening questions.

“Well, he has allergies, chronic bronchitis and fibromyalgia. If he’s worse than usual, reschedule, but if he’s the same as always, I’ll see him”, I answered.

Mr. Swift’s wife told me he has diarrhea ten minutes after every meal, sometimes even fecal incontinence. When I asked how long that had been going on, she said two years, ever since his colon resection. And yes, the surgeons knew about it. The Swifts just never mentioned it to me.

“How long have you had these headaches?” I asked Randy Blake. “A while”, he answered. “Ballpark? A week, a month, a year?” I asked. “Maybe two or three years” was his reassuring answer. Not that it couldn’t be something serious, but it certainly wasn’t a fast moving disease.

It is striking, how often I as a physician am presented with a symptom without any information about its duration, speed of onset or progression. But that, the time factor, is usually the most important part of a case history.

Our bodies tend to be in a fairly steady state: Our weight, energy level, appetite, elimination habits and even our mood tend to vary only within a certain range. The more things deviate from that typical range and the faster this occurs, the more aggressively we tend to pursue an explanation.

A typical example of this is the kind of patient who comes in for a routine visit, 15-30 minutes at most, and mentions more than half a dozen symptoms just to be sure they’re not serious. One patient I had even said “just so it’s in my record”. Taken the wrong (?) way, that could even be seen as building a case against me in case one of those symptoms later turned out to be something serious that I overlooked.

Think of this as one of those sets of near-identical pictures where you have to spot the difference. That’s usually an easier task than finding something wrong with one single picture; our brains are wired to compare, and that’s easier with a real set of pictures than one faulty picture we have to compare with our internal vision of what things should look like.

Also think of this as considering the inevitability of age related changes. If someone seems to age more rapidly than we are used to, look for disease. Graying hair in a middle aged person is expected, but in a twenty year old it is very unusual. (That, by the way, is how I explain osteoporosis, T-score and Z-score to my patients.)

Timing is everything.