Good Story!

My patient complains of chest pain a few days ago while mowing the lawn. He has no chest pain today, but his story is so good I decide to order an EKG, bloodwork, and some other tests. I start running the differential diagnosis algorithm in my mind; sometimes, a patient history is all I need to make a diagnosis.

His EKG is normal, but his cholesterol is high, so I start him on a cholesterol-lowering statin and order an exercise tolerance test. I wag my finger at him and say, “Your story is so good that I’m worried. If you get chest pain again, please go to the ER.” For now, he goes home and returns to his routine—job, family, housework.

Three days later, he has chest pain again and goes to the ER. His troponins are negative and his EKG is normal, but “his story is so good he deserves admission for observation.” Instinct prevents the inpatient doctor from sending him home within the usual 24 hours, and a stress test is scheduled. The stress test paints a different picture; specialists are called in, and they recommend more evaluation and invasive procedures—probably bypass surgery.

He becomes a teaching moment for residents and students on “why we should listen to our patient and our instincts.” He has gone from a middle-aged male with chest pain to a middle-aged male with severe coronary artery disease.

After being told his options, he says he’ll just rest more: “This chest pain is brought on by exercise, so I’ll have my son mow the lawn.” Neither the cardiologist nor the inpatient team can convince him otherwise, so they call me in to see if I can change his mind.

I spend time with him, reviewing all the tests and explaining everything. He says he appreciates it all but is overwhelmed by the suddenness of it. He insists on going home to think, decide, change his lifestyle, and take his cholesterol medication. He feels the problem will go away, and we can check his cholesterol levels again in three months. He does not wish to have further conversations and is discharged against medical advice.

Initially, I’d patted myself on the back for doing the initial workup and warning him to beware of further chest pain. The admitting team had patted themselves on the back for admitting him despite the negative tests and working him up. The cardiology team had patted themselves on the back for expediting his care and getting the further testing done quickly.

But now all of us are worrying: When will his heart muscle give way, and will we be able to care for him when it does?

Nidhi Lal
Acton, Massachusetts