Manuel came in right after his wife this morning. Because of his complaint of chest pain, the nurse was on top of things and had an EKG done before I got in the room. It was normal. He was complaining of pain as motioned with his hand over his right chest, showing how the pain started just to the right of the sternum and radiated over the whole right side of the ribs, was worse with deep breaths, and accompanied by a little shortness of breath. It's been going on since last Tuesday, but he waited 6 days until today to come into see me.
Going back over the his story, Manuel described the day that the symptoms began. It was the day after Labor Day when suddenly the weather turned very hot and muggy, after a long spell of cool temperatures. It was very hot at work in the greenhouse. Someone offered him ice water to cool down. From the moment he took the first swallow of ice water, he began to feel the pain, and it has not relieved since it began.
We western physicans call this kind of pain "pleuritic", a sharp pain that increases with the depth of respiration. It almost always excludes serious sources of pain such as pneumonia and heart attack ( but not always!) Serious conditions such as a blood clot in the lung could be considered, but a vigorous man in his 40's without predisposing conditions, Manuel has a low probability of that. Much more likely is irritation of the muscles, ligaments of the chest wall, or even irritation of the sac like covering of the lungs. After all, this would not be unusual -- 2 other people had already been in with viral flu-like illnesses today with the same symptoms.
But what makes Manuel's description unique and so different from my other patient today, a computer network administrator, is the emphasis on change in temperature. In Manuel's world, the ancient world of hot and cold, illness is caused by a disruption of the balance cold and hot forces in the body. In his view, heating the body up unusually put Manuel at risk of illness, because any sudden cold impulse, whether it be ice water, ice cream, walking on a cold floor, or walking into air conditioning could disturb the balance, and set off illness.
I check Manuel's oxygen levels which are normal, and then send him off for a chest X-ray. I am going to treat him with ibuprofen for muscular and ligamentous pain, but how do I treat him in a way that makes sense to his traditional sense of hot and cold upended?
We western physicans call this kind of pain "pleuritic", a sharp pain that increases with the depth of respiration. It almost always excludes serious sources of pain such as pneumonia and heart attack ( but not always!) Serious conditions such as a blood clot in the lung could be considered, but a vigorous man in his 40's without predisposing conditions, Manuel has a low probability of that. Much more likely is irritation of the muscles, ligaments of the chest wall, or even irritation of the sac like covering of the lungs. After all, this would not be unusual -- 2 other people had already been in with viral flu-like illnesses today with the same symptoms.
But what makes Manuel's description unique and so different from my other patient today, a computer network administrator, is the emphasis on change in temperature. In Manuel's world, the ancient world of hot and cold, illness is caused by a disruption of the balance cold and hot forces in the body. In his view, heating the body up unusually put Manuel at risk of illness, because any sudden cold impulse, whether it be ice water, ice cream, walking on a cold floor, or walking into air conditioning could disturb the balance, and set off illness.
I check Manuel's oxygen levels which are normal, and then send him off for a chest X-ray. I am going to treat him with ibuprofen for muscular and ligamentous pain, but how do I treat him in a way that makes sense to his traditional sense of hot and cold upended?
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