If At First You Don't Succeed...

Testing is important in practicing medicine. In principle, we don't like to repeat tests. However, sometimes it is necessary. My experience with the following patient illustrates this principle.

An elderly woman with heart disease was having episodes of moderate to severe chest pain. Several years earlier she had undergone coronary bypass surgery for chest pain, and after the surgery the pain had resolved. Now it was back.

The patient's cardiologist had done the appropriate testing, including coronary angiography, and had concluded that the chest pain was not originating from her heart. Among the diagnoses he considered as a cause of the chest pain was an esophageal motility disorder, or more specifically, esophageal spasm. He asked me to evaluate his patient for this possibility.

At the time I saw her, the patient was in the coronary observation unit, having just been admitted to the hospital after one of her episodes of chest pain. I went to her room, pulled up a chair, and began reviewing her medical history. One of the first questions I asked was whether a full electrocardiogram (EKG) had ever been obtained while she was at the peak of an episode of chest pain. Since the episodes lasted only a few minutes, the answer was no. (There never was enough time to get to the emergency room or doctor's office while the pain was still present.)

About 15 minutes into the history, the patient appeared uncomfortable, squirming about in her bed. I asked her if anything was wrong. She replied that she was having chest pain, and it was getting worse. I reached for the nurse's call button at the side of the bed and ordered an immediate EKG. Approximately five minutes later, the EKG technician arrived and began hooking up the recording leads for the EKG. I asked the patient how she was feeling, and she replied that the pain was still present but was easing. The EKG was completed. Comparing it with the EKG that was done at the time of her admission, I saw no changes. That is, there was no evidence that there was a new cardiac problem to explain the just-resolved episode of chest pain. An esophageal problem was looking more likely.

I continued taking her history. A short time later, she again began squirming about in the bed. The chest pain was returning. My first impulse was to order another EKG. I hesitated. I'd already been "burned," that is, the EKG that had just been done had been unrevealing. Wasn't another EKG likely to be as unrevealing as the first and be wasteful? On the other hand, the prior EKG had been done when the chest pain was resolving. Perhaps if I ordered another EKG, it could be obtained while the pain was still at its peak. I pushed the call button again.

The EKG technician arrived looking a bit disgruntled. I knew what she was thinking. The pain this time, unlike the last test, continued while the EKG was obtained. I reviewed the EKG. It was dramatically different from the EKG done at the time of admission. The chest pain clearly was cardiac in origin.

Sometimes, you just have to do it again.

Medical Author: Jay W. Marks, M.D.

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