TELE MEDICINE

This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome

This is a deidentified  patient record with information interpreted from an audio call with the patient , posting here after attaining verbal consent from the patient, by student doctors (Saahithya Reddy Gangi -141 , Sana Sai Bhavana -146  and  Nikhitha Pulipeta- 130) under the guidance of Dr. Rakesh Biswas sir

A 45 year old patient who is a politician came to the hospital with the 

Chief complaints :
Right sided chest pain since May 3rd.
History of present illness :
The patient was apparently asymptomatic before May 3rd  He developed localized  pain in the  right side of the chest region just beside the midline.It was insidious in onset and gradually progressive for the first 3 days and persistent for next 20 days.  It was dull aching type which was non -radiating. The pain was aggravated on inspiration, coughing, even by mild movement, talking ( he slept only on one side because pain would cause more discomfort on movement) . Relieved on medication.

Associated factors are :

• Pricking type of pain developed on the back just opposite to the localized pain in the chest. This pain has insidious onset which occurs in episodes (for every 3-4 hours approximately)  and lasted for 4-5 secs. It is of pricking type. 
• Pain  in the right shoulder ,arm, forearm. 
• Tingling sensation in the ring and little finger.  
• He felt mild stony hard like swelling on palpating himself  at the  region of pain but no other skin changes 

H/o playing  carroms in  the mobile phone since the lock down has started and played hours together(15 hours  a day)  continuously with his left arm on the bed and strains  right arm by lifting up while in supine position. (could this be the reason for the pains he's developing on right side???) 🤔
H/O neck pain since 10-15 years. He told that he used 2-3 pillows while sleeping every day.
H/O accident 15 years ago (a bike hit on his lower back)  for which he was treated. But few episodes still occur sometimes.
H/O tingling sensation while squatting for about 10 mins (is it normal??)🤔
H/O hawking(frequent clearing of throat)
H/O burning sensation in central chest or upper central abdomen since 16 years which occurs after taking oily foods which was relieved by 'ENO '. He told that he never felt hungry and takes only 2 meals a day for which he visited hospital and was diagnosed with acidity and he was given medications but he didn't use them as he  felt the problem was because of improper schedule of his meals. Since the lock down he started eating 3 meals /day and walks for about 4-5 kms in the evening everyday. Now he says theres no feeling of acidity anymore.
No H/O palpitations,cold sweat, dizziness,Nausea ,vomiting,  vertigo,  headache, shortness of breath.
No H/O  cough, fever, cold, wheeze,hemoptysis.
No H/O recent trauma.
No H/O pressure, tightness, numbness or burning sensation felt at the site of pain in the chest.
No H/O fullness or squeezing.
No H/O edema.

Treatment history :
The patient developed mild pain on 3rd May  for which he visited local RMP doctor but pain didn't subside .He was treated for 15 days in the clinic and then he visited cardiologist after 15 days of onset of pain .
It was relieved on medication within 4 days. He still has few episodes of pain which relieved on
Medical history :
Acid indigestion since 16 years.
He's not a known case of hypertension, diabetes mellitus,  bronchial asthma, thyroid, coronary artery disease,TB ,epilepsy

Drug history :

• Eno since 16 years. 
• Tab : Met -XL 25 my 
• Tab : Mactor-ASP
• Tab : Pantotas 
• Tab : Aceclo plus 
• Tab : Paracetamol 650 mg

Following medications were prescribed by local 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 diet ( includes high fat diet)
(suspect of hyperlipidemia)
Appetite : low appetite before and increased since lockdown
Sleep : adequate
Bowel and bladder movements :Regular
Addictions : chronic alcoholic ( weekly 3 times and 2 beers each time). He stopped drinking alcohol completely since 8 months.

                   
                            Site of pain
Investigations done :
        Reports at hospital 1
           Colour Doppler 2d echo

Troponin test

Thread mill test

X-ray chest 

                      X-ray  cervical spine

ECG

Reports of hospital -2

                     

ECG at hospital

Interpretation of ECG :

V3 - biphasic T wave

Lead 1 , lead 2  and V4, V5, V6- shows T wave inversion ,a STRAIN PATTERN

( If S complex from V1 or V2+ R complex from V5 or V6 >3.5 mm - LVH) 

This ECG shows nearly left ventricular hypertrophy. 

2d Echo video

                  2D - ECHO
             Interpretation of 2D-Echo :
              Left ventricular hypertrophy.


Our thoughts :

• Burning sensation in his chest and epigastrium  seems like GERD but it could also be "Silent MI.  "
• The pain in his chest and right upper limb might be due to overusage of phone without resting it .(leading to strain) 
• Lower backache and tingling in squatting position might be due to the nerve compression which might have occurred in a bike accident 15 yrs ago. 
• It could also be Costochondritis due to the tenderness present at the site of pain. 
• We can also think of Tietze syndrome as the patient felt a swelling at the area while palpating himself. 
• In investigations TMT - positive (heart rate - 292b/m ) . (Normal heart rate in TMT of 40 yrs - 180b/m)  . This may be due to compensatory increase in heart rate when put under stress due to some underlying cardiac pathology.
• A study  shows that some of the false positive cases have been seen in Obstructive Coronary Artery Disease. https://academic.oup.com/eurheartj/article/34/suppl_1/P3375/2861932.
• According to the ECG reports and 2D - ECHO we can also think of Left Ventricular Hypertrophy.( As there are  inverted T waves ) in lead 1 ,lead 2,V4,V5,V6 (stress pattern) there is suspicion of Myocardial Ischemia. 
• As our patient consumes high fatty diet there may be Atherosclerosis in the vessels. 
• No other risk factors like smoking, hypertension,  diabetes are present other than Lack of physical activity, Age,  High fatty diet, Alcohol. 

Investigations needed :
Coronary Angiogram
Lipid profile

• DIFFERENTIAL DIAGNOSIS :

1. Left ventricular hypertrophy 
2. Silent MI
3. Costochondritis / Tietze syndrome
4. GERD

Queries??? 🤔🤔

• Was osteophyte growth due to excessive neck strain? 
• Is the tingling sensation in his 4th  and 5th digits of right upper limb due to osteophyte growth  Causing compression of C8 ( C8 Radiculopathy) 
• Is 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.