This Time, it’s Different: The Man Who Cried Wolf and the Doctor Who Listened

(A piece from 2021 with a lesson we must never forget)

Andrew White had a long history of non-cardiac chest pain, usually fitting the definition of costochondritis, or Tietze’s syndrome. His pain was sharp, localized high up to the left, not far from his collar bone. He was always tender to the touch there and his EKG and bloodwork were always normal.

Between his recurring chest pain and other symptoms, like belly pain and swelling with pain in his legs, Andrew had logged half a dozen emergency room visits in the first 9 months of this year. Each time, he had called the ambulance to get there.

Then one day, during a regular office visit, he told me about a new pain he’d been having. Because he doesn’t drive, he usually walks to the store. For the past two weeks, he had noticed some shortness of breath on the way back up the hill to his apartment. Also, he had felt a pressure more in the middle of his chest.

Was this the power of suggestion after being asked about such symptoms every time he had been to the emergency room? Or was it the real thing this time?

His exam and EKG were normal.

I did not take any chances. I put him on a long acting nitroglycerin plus PRN sublingual tablets with careful instructions on how to use them. I also prescribed atorvastatin and ordered an ASAP nuclear, chemical, stress test and told him under which circumstances to call 911, even though I had discouraged him from doing so for other symptoms before. I didn’t start a betablocker because his blood pressure was on the low side, but I scheduled an early followup.

His stress test was only mildly abnormal, but his cardiac cath showed a near total occlusion of his left anterior descending coronary artery. This is the big one that has been called the “widow maker”.

The lesson here is obvious. Even worriers and hypochondriacs get bad diseases sometimes. We must never dismiss or underestimate that possibility.