This is an Online E Log Book to discuss our patient's de-identified health data shared after taking her signed informed consent. Here we discuss our patient's problems through series of inputs from available global online community experts with collective current best evidence based inputs.
In this case the 56 year old female is a homemaker with the medication of Migraine, DM, Hypothyroidism. She also has the problem of tinnitus since 2019 without any medicine. The patient does yoga and pranayama regularly for one hour in the morning.
Recently she had pain in the left side of her chest with sweating and severe headache with weakness. The chest pain lasted for 2 hrs. The pain started after she did her regular yoga and was having coffee. She managed with her domestic work thinking it to be due to gastric problem. She was advised and taken to hospital for emergency consultation as the pain was connected with sweating.
Below are the reports of the patient.
PA - ECG reports.
PA - 2D Echo
PA - Colour and Doppler Study.
PA - HS Troponin report.
PPM 1 - The first impression is that they are all normal and unchanging and un evolving hence reassuring.
If this is the first ECG there will always be diagnostic uncertainty attached as there is no previous ECG to compare with if anything may have changed recently. Hence can be labeled borderline to hide the doctor's uncertainty.
I don't see much significant change between what has been labelled abnormal and otherwise normal in these two ECGs
While studying and interpreting ECGs it's always a dictum that the patient is more important than the ECG because one can have a heart attack even with a normal ECG.
We never look at what the computer automatically prints. Ideally both the computer's as well as our cognition should match but currently they don't as the computer's training is different.
PA -
"Ok madam
Better to start medication.
Tab ROSUVAS 40 mg OD 9pm
Tab ECOSPRIN 150 mg STAT AND OD 2 pm
"Better get done CT CAG madam"
PA - 👆advised by cardiologist.
PPM 1 - I can't agree with this advice but then I'm biased because i may have more data than the cardiologist.
PPM 2 - 😅
PPM 1 - The above will be a great case report in isolation just focusing on this theme of "clinical electrophysiological diagnostic uncertainty around chest pain"
PPM 2 - 👍
PA - CT CAG should be done?
PPM 1 - Not at all.
PA - Okay thank you so much. Hope nothing to worry.
PPM 1 - It will definitely show some blockages (even for asymptomatic me if not @PPM2) because that's a process of plaque formation that humans can't avoid.
There are always a million causes to worry if one wants to worry!
PA - You are right. We shouldn't worry at all.
The patient is experiencing mild breathlessness when she bends and does some dusting, or changes the bedsheets and while climbing the stairs.
PPM 1 - The patient is very likely to be having cardiac dysfunction due to CAD as an explanation for the symptoms.
What we disagree with the cardiologist is with their proposed solutions for this.
We believe that currently life style modifications and some other doubtful pharmacological prophylaxis is the only scientific way to go about it.
However one also needs to rule out a lung or bronchial cause for that by doing a peak flow metry before and after the onset of these symptoms as in seeing the temperature with a thermometer. You may recall our suggesting it to another patient.
PPM 1 - Here are the causes of false negative troponin👇
PA - Atorvastatin Tablets prescribed by PPM 2.
PPM 1 - Looks like the system is trying to blame the patient @PPM2 instead of reflecting on their own incompetent medical education system!
CRH Gist:
Didn't do CAG as advised so discharged as left against medical advice!
If unnecessary CAG had been done and turned out normal patient would have left as per medical advice (the LAMA tag is true either way) and no one would have bothered to reflect on why the patient has to go through a torturous angiography just because their doctors don't know any better!
PPM 2 - Absolutely. Patients here are so accepting of humility and not knowing, wonder why it is so aversed there.
PPM 1 - An interesting paper relevant to our PaJR patient's recent visit to the emergency with chest pain 👇
Highlights
•
Acute coronary syndrome (ACS) overdiagnosis is more common than underdiagnosis
•
Male sex and elevated high-sensitivity troponin are the main causes of ACS overdiagnosis
•
Female chest pain (CP) patients have lower pre-test probability of ACS according to emergency department (ED) physician management
•
Women with CP are more likely discharged early from the ED without apparent differences in 6-month cardiovascular outcomes
Unquote
19-02-2025
PPM 2 - Extremely rare and all those false negative causes are effectively eliminated. Although lipemia is suggested as one, it is more likely from Heterophile antibodies than the lipids themselves.
PPM 1 - 👍
24-02-2025
PA - Saturday night when the patient went to bed, she felt her left shoulder heavy and could not lift or move easily. And had pain in the left side of the chest alongwith pain in the shoulder too. It continued for one hour and after that she could sleep. Again in the midnight at 12.40am she experienced the same for almost one hour. Now also the same experience with mild chest pain and shoulder pain accompanied by her regular problem of migraine and nausea. She has have taken Sumatriptan just now.
PPM 1 - Any events related to this patient involving increased strain on the left shoulder and neck on Friday or Saturday morning?
PA - Nothing like that. Even now she has the pain after taking rest the whole night with good sleep. Slowly it is subsiding. Have applied coconut oil and got massage done.
PPM 1 - 👍
It's difficult to recall and share all activities that a person may have done throughout the day that may have strained the muscles and ligaments around the left shoulder neck and chest.
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