M. P. Ravindra Nathan

LOW-TECH DIAGNOSIS
'WHITHER ARE YOU GOING, MEDICAL MAN?’

By M. P. RAVINDRA NATHAN, MD, FACC, FACP

Occasionally, I get a chance to see general medical cases in my heart clinic. A lot of my patients who have established with me for their cardiac problems would come running if they have non-cardiac problems especially if it is urgent. I didn’t mind that since I know them well for a long time and most of them are my friends now. Also, it made me feel that I am always in their confidence.

Alfred, a sprightly 78 years old, was such a person. Al was friendly and popular with our staff and sometimes brought them oranges from his yard or chocolates in nice boxes. Whenever he went to Wisconsin where he had a summer cabin on the lake, he would call me up for advice rather than going to the local doctor. But one day, he canceled his scheduled appointment because he had to run to the dentist to take care of a severe toothache. I said that was fine because toothache can be annoying.

A few years ago, Alfred suffered a heart attack and had to undergo cardiac catheterization, a special test to detect any blockage of his coronary arteries. This was followed by successful angioplasty. Lately, he had become fatigued and his heart rate had become slow, often dipping into the 40s although he was not on special drugs, which might decrease his heart rate. He had a degree of low thyroid function, which sometimes can decrease one’s heart rate. But this was well treated and his ‘hypothyroidism’ had always been under control and recent thyroid profile showed normal values.

A recent 24 hr EKG (Holter) monitor showed that indeed he had significant ‘sinus bradycardia’ with heart rate dropping to 35 beats/ minute at times. That is why he was asked to come to the office for further evaluation and discussion of permanent pacemaker implantation. And this was the appointment he missed.

When he finally showed up in the office two weeks later, my first question was about his toothache.

“Oh, man, I am still hurting,” he started, pointing his fingers to the right side of the face. “First, I went to the dentist because the pain was all around the right teeth. He took this panoramic view of X-rays of all my teeth, upper and lower and said there is nothing wrong with them. I got a good cleaning of my teeth anyway. Then, I saw an ENT specialist who examined me and got an X-ray of the sinuses, which was normal. But he wasn’t satisfied and so he sent me for an MRI of the head, which also turned out to be normal. I got some pain pills but doc, they are not working.”

The anguish in his face was almost palpable and there was a sense of plea in his words. As an afterthought he added, “Boy, those tests aren’t cheap.”

Now that you had all kinds of high-tech investigations and they couldn’t find anything wrong, let us get back to the basics, I told myself.

“Al, tell me a little more about this pain,” I asked him. The description was quite diagnostic. The pain occurred as brief lightning stabs every few minutes on the right side of the face, often precipitated by simple touch. Sometimes, it shot from the orbit or temporal region down to the chin. Clearly, the pains were frightening and he had tears welling up in his eyes. The neurological examination was entirely negative. A good history and one look at the face was all that was needed to make an instinctive diagnosis, ‘trigeminal neuralgia.’

I asked him, “Why didn’t you call me earlier? May be I could have saved you some money?”

“Why, you know the answer?” He looked at me expectantly.

“I think, I do. You have inflammation of one of the nerves on the side of the face. We call it trigeminal neuralgia, pretty painful condition.”

Al was started on Tegretol, the standard drug for this condition and in two days his pains abated. At my request, he saw a neurologist for confirmation and future follow-up. We postponed the discussion of pacemaker temporarily. When I saw him two weeks later, he was smiling heartily and thanked me profusely. “I should have simply called you instead of going for all those tests,” he jokingly remarked. But I told him those tests did help to rule out other diseases, which might mimic this condition and certainly they made my job easier. But I knew in my heart, they were probably unnecessary.

Medicine is an art and science and clinical history is still paramount in the initial diagnosis. In the rush and tumble of a busy practice, we don’t have much time to listen to the patient’s story and tend to rely heavily on laboratory tests. The traditional clinical medicine is gradually being replaced to a great extent by ‘techno-ritualism’ with its associated economic boom. ‘The patient in the computer’ has become more important than the patient in the bed. A good history could have easily helped to diagnose this condition and start an early treatment with no additional expenses. One of my senior colleagues, a learned pediatrician, always asks the question: “Quo vadis medici?” (Whither are you going, medical man?).

I don’t think we know the answer.

• Reprinted from Cortlandt Forum

Cardiologist Dr. M. P. Ravindra Nathan, director of Hernando Heart Clinic in Brooksville and editor-in-chief of the AAPI Journal, lives in Brooksville.

GAINESVILLE ASSISTANT PROFESSOR HONORED

Story provided by American Society of Transplantation

	Dr. Vikas R. Dharnidharka

On July 24, Dr. Vikas R. Dharnidharka will be honored by the American Society of Transplantation with the AST Achievement Award for Assistant Professors in Clinical Science at the World Transplant Congress in Boston. The Gainesville resident will receive a plaque and $10,000.

Dharnidharka, a pediatric nephrologist by training and an assistant professor of Pediatrics at the University of Florida, is considered one of the world’s experts in post-transplant lymphoproliferative disease (PTLD). This rare condition is an unusual malignancy in transplant recipients that in most cases is caused by a virus infection.

The AST unsolicited achievement awards are the highest honors that the society awards to members of the transplantation community. Nomination and award selection are made by peers within the transplant community and a candidate cannot be self-nominated. Awards are given at three levels: Professor, Associate Professor and Assistant Professor, to recognize outstanding contributions at each level.

AST is the premier society for transplant professionals, comprising more than 2500 members from diverse specialties such as nephrology, gastroenterology, cardiology, pharmacology, immunology, surgery and infectious diseases.

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