TELE MEDICINE

This is a de-identified patient online record with information interpreted from audio call with the patient, posting here after attaining verbal consent from the patient,by student doctor(Saahithya-141, Nikitha- 130, Sai Bhavana - 146) under the guidence of Dr Rakesh Biswas sir.

A 45 year male patient who works as a political leader has come to hospital with 

Chief complaints:

 Right sided chest pain since may 3rd.

History Of Present Illness: 

Patient was apparently asymptomatic before may 3rd. He developed localized pain which is on  right side of mid-line. It was insidious in onset, which is dull aching type and non radiating. Pain was gradually progressive for  3 days and remained persisted. Pain is aggravated on mild movement,coughing and inspiration. Pain was relieved on medication.He used to sleep only on one side due to pain and was not able to move even a little bit during sleep.It was associated with some episodes of pricking type of pain on back side just opposite to the localized pain in the ant chest wall.Pricking types pain was insidious in onset and lasted for small duration (2-3 secs for every 4 hours).He felt mild stony hard swelling on palpation at the site of localized pain.

He also has a history of pain on the shoulder,arm, little finger and ring finger( tingling was present).

He told that during the lock-down period as he did not have any work, he used to play carroms in the mobile for 12 -15 hours for 2 months continuously. He plays the game in the supine position with 2 to 3 pillows under the neck with left arm  resting on the bed and stains his  right upper limb while playing.COULD IT BE THE REASON BEHIND HIS CHEST PAIN?????

He also told that he had a history of mild neck pain since 10-15 years which may be due to use of 2-3 pillows.

 

There was a history of accident 15 years back (bike hit on the lower back). Pain was present in the lower back region and was relived after using medications. But some episodes of back pain are still present.He also had tingling sensation in lower limbs while squatting for 10 min(Is it normal??)

He also had history of hawking (frequent clearing of throat). He also gave a history of burning sensation in the central of chest and upper central abdomen after taking oily and fatty meals (which is relived by taking ENO) since 16 yrs. He told that he never felt hungry and he takes only two meals a day. For this he visited hospital and  was diagnosed with acidity. He didn't use medications, as he couldn't take meal properly in normal timing. After lock-down he started taking meals 3 times a day and stated walking for 3-4 kms everyday. Know he says there is no acidity.

No history of recent trauma

No history of palpitations,giddiness,SOB,headache,burning sensation

No history of fullness and squeezing.

No history of edema

No history of cough,cold, hemoptysis, wheeze

No history of anxiety

No history of redness, skin changes 

Treatment history:

Then patient developed mild pain on the right side of the right side for which he visited local rpm,  where he was treated for 15 days in clinic. Then he visited a cardiologist after 15 days onset of pain and it was relieved by medication within 4 days.He still has few episodes of pain which only relieved after taking medications.

Medical history

There is no history of similar complaints in past. Not a known case of hypertension, coronary artery diseases, diabetes mellitus, thyroid problems.

He has history of acid indigestion since 16 yrs.

Drug history

He has been using ENO, when he gets burning sensation after eating.

Tab Met XL 25mg

Tab Mactor asp 

Tab Pantotas

Tab Aceclo plus

Tab Paracetamol 650mg

Following medication have been prescribed by rmp 

Tab Ultracet

Tab Hifenac -P 

Tab Nexpro-40

Tab Hexagab SR

Tab Rabegard

Tab Beplex

Tab Montair

Family history

No significant family history

Personal history

Diet: mixed type and consumes high fatty diet(suspect of hyperlipidemia)

Appetite:decreased appetite and significant increase in appetite during lock-down

Sleep:adequate

Bowel and bladder movement: regular

Addictions:chronic alcoholic (weekly 3 times and each time 2 beer). He stopped drinking completely since 8 months.

SITE OF PAIN

INVESTIGATION

ECG: V3 - biphasic T wave

Lead 1 ,2V1, V2, V4, V5, V6 show T wave inversion

Left ventricular hypertrophy

Our thoughts in this case

• Burning sensation in his chest and upper epigastrium seems like GERD but could as be silent MI.
• Pain in his right upper limb and right chest region may be excessive use of smart phone in abnormal position.
• Lower back pain and tingling sensation in the squatting position may be due to accident causing compression of nerves.
• It could be costochondritis as there is tenderness on palpation.
• We can also think of Tietze syndrome as patient has swelling at the area of tenderness
• In investigation TMT was positive(292bpm).This may be due to compensatory increase in heart rate due some underlying cardiac pathology.A study shown that,in some patients, a false positive TMT can be seen in obstructive coronary artery disease

https://academic.oup.com/eurheartj/article/34/suppl_1/P3375/2861932

• As our patient consumes high fatty diet there may be atherosclerosis in the vessels.No other risk factors like smoking, hypertension,DM are present.Other than lack of physical activity,age, alcohol
• According to the ECG and 2D ECHO we think of left ventricular hypertrophy.
• As there are inverted T waves in V1,V2,V4,V5,V6 ,we think that there maybe myocardial ischemia.

INVESTIGATION REQUIRED ARE

• Coronary angiogram
• lipid profile

DIFFERENTIAL DIAGNOSIS

• 
  
• Left ventricular hypertrophy
• Silent MI
• Costochondritis/Tietze
• GERD

QUERIES

• Was osteophyte growth due to neck stain???
• Is the tingling sensations in 4th and 5th digits of right upper limb is due to osteophyte growth causing C8nerve ( C8 RADICULOPATHY).
• Is the left ventricular hypertrophy due to hypertrophic cardiomyopathy??
• Did ALCOHOL effect the heart??

We thank our patient to be so cooperative and comfortable to talk to us on phone.

 My colleagues blog. Please take a look at them too .

https://nikhithapulipeta130.blogspot.com/2020/05/did-overuse-of-mobile-phone-wreck-his.html.

https://medcases.blogspot.com/2020/05/this-is-de-identified-patient-online.html.