TELE MEDICINE

Hello all!
This is a de-identified patient record with information interpreted from an audio call with the patient,  posting here after attaining verbal consent from the patient, by student doctors ( Sai Bhavana 146, Gangi Saahithya 141,Nikhitha pulipeta 130)under the guidance of Dr.Rakesh Biswas Sir.

A 45 year male patient who works as a political leader has come to hospital with the chief complaint of:
Right-sided chest pain since 3rd may

HOPI: 
  • Patient was apparently asymptomatic before may 3rd
  •  The pain was insidious in onset and gradually progressive for the first three days and then it was persistent for the next 20 days.
PAIN:
  1. SITE: He developed localised pain which was just rightside to the midline in the chest region
  2. CHARACTER: Dull aching type of pain
  3. RADIATION: no radiation
  4. AGGRAVATING FACTORS: Pain aggravated on inspiration, coughing,  talking(he could only speak slowly due to pain), and even mild movement( the pain not even made him move a bit during his sleep).
  5. RELIEVING FACTORS: relieves on medication.
  6. ASSOCIATED FACTORS:
  • Pricking type of pain Was present on the back which was at the quite opposite region to the localised pain.
                          ↪ Pain Was pricking type and has insidious onset which occurs in episodes (for every 3 to 4 hours) and lasted for 4 to 5 seconds
  • Pain in right shoulder, arm and forearm and tingling sensation in his right side ring and little fingers
  • On palpation he felt he felt stony hard swelling at the site of pain.
HISTORY OF CARROMS: 
  • H/o Online caroms in the mobile phone since lock down has started and he used to play it for about 15 hours a day
  • Position during playing: every time he plays the game he will be in supine position with two pillows under his neck and left arm resting passively on the bed and strains his right upper limb while playing the game( could this be the reason for his pain on the right side).
HISTORY OF NECK PAIN:
  • History of mild neck pain since 10 to 15 years
  • He told that he uses 2 to 3 pillows while sleeping every day
HISTORY OF BACK PAIN:
There is history of accident (a bike hit on his lower back)15 years ago for which he was treated but few episodes of back pain still occur sometimes

FEW OTHER COMPLAINTS:
  1. History of tingling sensation in lower limbs while squatting for about 10 minutes[is it normal?]
  2. History of Hawking [frequent clearing of throat ]
  3. H/o BURNING SENSATION in the central chest and upper central abdomen which occurs after taking fatty/oily food and relieves by ENO. (Since around 16 years.)
  • He told that he never felt hungry and takes only two meals a day
  • For this he visited hospitals and diagnosed with acidity but he didn’t use those medication. [As he felt that acidity problem was only because of improper intake of meals.]
  • Since the lock down he started eating three meals per day and walking for about 4 to 5 km in the evening every day. Now he says there is no feeling of acidity anymore.
NEGATIVE HISTORY:

  • No H/O recent trauma
  • No H/or palpitations, cold sweat, dizziness, vertigo, nausea, vomiting, headache, shortness of breath 
  • No H/O Pressure, numbness or burning sensation felt at the sight of pain 
  • No H/O fullness or squeezing in the chest
  • No H/O swelling of legs, ankles, and belly
  • No H/or fever, cough, cold, Wheeze, haemoptysis
  • No H/or anxiety or stress felt recently
  • No H/O Redness, skin changes at the site of pain
  • No H/O fatigue 
TREATMENT HISTORY:
  • The patient developed mild pain on 3rd may.
  •  For which he visited local RMP where he was treated for about 15 days in the clinic.but the pain didn’t subside 
  • Then he visited a cardiologist after 15 of onset of pain and it was relived on medicated within 4 days.
  • He still has few  episodes of pain which only subsides on medication.
    MEDICAL HISTORY:
    • No previous similar attack
    • Not a known case of hypertension, diabetes, bronchial asthma, Coronary artery disease, thyroid disorder, tuberculosis, epilepsy
    • Acid indigestion since 16 years

    FAMILY HISTORY:
    No similar complaints in the family.

    PERSONAL HISTORY:
    1. DIET: mixed type of diet I am confuse high-fattydiet [suspect of hyperlipedemia]
    2. APPETITE: decreased appetite since many years significant improvement of appetite during lock down
    3. SLEEP:Adequate
    4. BOWEL AND BLADDER MOVEMENTS: Regular 
    5. ADDICTIONS: chronic alcoholic [ weekly 3 times , 2 beer’s each time] . He stopped drinking completely since 8 months.
    DRUG HISTORY:

    • Has been using ENO since 16 years
    •   Tab.Met XL 25 mg
                   Tab.Mactor ASP
                    TAB.Pantotas
                   TAB. Aceclofenac.
                  Tab.paracetamol 650mg
    • Following medications have been prescribed by RMP:
                     Tab.Ultracet
                     Tab. Hifenec
                     Tab. Nexpro 40
                     Tab. Hexagab SR
                      Tab.Rabegard
                       Tab .Beplex

                    Tab.Montair


    SITE OF PAIN


    INVESTIGATIONS :

     Reports at hospital 1:
    1. color doppler and 2D echo
    2. Trop I test report



    3.Treadmill stress test


    4.X-Ray chest PA view




    5.X-RAY cervical spine


    6.ECG

    REPORTS OF HOSPITAL 2










    ECG at hospital
    Interpretation of ECG :
    V3 - biphasic T wave
    Lead 1 , lead 2and V4, V5, V6- shows T wave inversion 
    ( If S complex from V1 or V2+ R complex from V5 or V6 >3.5 mm - LVH) 
    This ECG shows nearly left ventricular hypertrophy. 








    Our thoughts on this case:

    • Burning sensation in his chest and egigastrium seems like GERD but it could also be "silent MI"
    • The pain in his chest and right upperlimb might be due to overusage of phone without resting it. [leading to strain]
    • lower backache and tingling in squatting position may be due to accident causing nerve compression.
    • It could also be constochondritis due to the tenderness present atthe site of pain.
    • we can also think of Tieze syndrome as the patient has swelling at the area of pain on self palpation
    • In investigations, TMT positive( 292 beats/min). Normal heart rate in TMT of 40 years is 180 beats/min.This may be due to compensatory increase in heart rate when put under stress due to underlying cardiac pathology.
                       a study shows that in some patients a false positive TMT may be seen in obstructive coronary heart disease
    click here for the study
    • according to the ECG reports and 2D echo,we can also think of Left ventricular hypertrophy.
    • as there ase inverted T-Waves in V1,V2,V4,V5,V6 [Stress pattern]
    • As our patient consumes high fatty diet, there may be atheroschlerosis in the vessels.
    • No other risk factors like smoking, hypertension, diabetes  are present other than lack of physical activity, age, alcohol and high fatty diet.
    INVESTIGATIONS REQUIRED:
    1. Lipid profile
    2. coronary angiogram.

    DIFFERENTIAL DIAGNOSIS: 
    1. Left ventricular hypertrophy
    2. silent MI
    3. costochondritis/ Tietze
    4. GERD 
    QUERIES:
    1. was the osteophytes growth is due to excessive neck strain?
    2. is tingling sensation in 4th and 5th digits of right upperlimb is due to oseophtic growth causing compression C8 ( C8 radiculopathy)?
    3. Did alcohol effect the heart?


    We finally thank our patient, as he was very co-operative and comfortable talking to us on telephone.

    THANK YOU!🙂





















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