Dr. Rakesh Biswas sir: Below shared in a Telemedicine group.
Can any student here phone this patient, create his detailed E log (case report) and discuss the approach to resolving his chest pain here?
Referring one case to you🙏
Consultation done by me 2 times but patient didn't benefit much.
Kindly advise what should be done next.
24 yrs
Unmarried male
student
Covid test - not done
C/o - severe chest pain ( mid of chest as mentioned) since 3 months
- happens when arched or bent down
- no pain on lying
H/o - vitamin D deficiency ( hence taking its supplementation)
- no family history
- no comorbidity
- no cough
- no breath less ness
- no history of travelling
- no trauma or accident happened
Medication - vit d supplementation and pain killers for treating symptoms
PROVISIONAL DIAGNOSIS-
COSTOCHONDRITIS
Rx-
Tab. Flexen MR one tab twice a day
Cap. Chymoral forte one cap twice a day
Tab. Cefixime 200 one tab twice a day
Cap. Omeprazole before breakfast
Continue for 7 days.
Pain not relieved.
Consulted again.
Cap. Tramadol 100mg twice a day
Cap. Chymoral forte one cap twice a day
Omnigel LA
Avinash Kumar Gupta: 24M, having chest pain at center of chest, mid of sternum, Localized at a point. Pain is mild, continuous 24*7 and increase when he changes posture like if bending up or down. Even in sleep if he changes posture he feels some pain.
Non smoker, alcohol 120 ml once a week, mixed diet, occasionally spicy food, eats nonveg and have upset bowel 3-4 times a month as diarrhea or constipation. Food 3 times a day including regular breakfast and occasionally evening snacks. No significant acidity or gas problems.
Patient have been a gym goer since 6 years , but not continuous and due to lockdown he have stopped gymming since a month before pain started. Average built body.
He is studying for CA for which to do intensive study he sits on table chair full day since 2016, and Continuing.
The medication recently given were the first time he consulted doctor and none of the medication were of any benefit.
Discussion below -
[9:26 PM, 5/22/2021] Divya PharmD, md: Sir ... Vitamin D deficiency may be related to the chest pain associated with costochondritis. Symptomatic treatment is followed and pt. relieves from symptom their own even if it persists for weeks or longer ...
Correct me if it's wrong ..
[9:28 PM, 5/22/2021] Dr. Rakesh Biswas sir: Share some literature around this particularly something that shows patient centered outcomes of vitamin D therapy as efficacious in chest pain
[9:32 PM, 5/22/2021] Divya PharmD, md: https://www.hindawi.com/journals/crim/2012/375730/
[9:33 PM, 5/22/2021] Divya PharmD, md: Conclusion from the literature sir .. 👇🏻
With treatment of deficiency and normalization of their serum vitamin D, both patients' costochondritis improved.
(history shared above)----
[9:46 PM, 5/22/2021] Avinash Kumar Gupta: Got the patient's history
[9:48 PM, 5/22/2021] Dr. Rakesh Biswas sir: Dr Dhivya after reading the two case reports in the link how sure can we be that the patients improved due to the vitamin d intervention and not due to it's placebo effect or even time alone?
[9:48 PM, 5/22/2021] Avinash Kumar Gupta: Pain on palpation.
[9:49 PM, 5/22/2021] Dr. Rakesh Biswas sir: Thanks Avinash. Can we find out if the pain started before or after administration of vitamin d?
[9:50 PM, 5/22/2021] Avinash Kumar Gupta: Yes sir. Before. Vit d started recently, a few days back. Pain started 4 months back.
[9:50 PM, 5/22/2021] Divya PharmD, md: Sir I thnk ... The cause might be his therapy too ! 😅
[9:51 PM, 5/22/2021] Dr. Rakesh Biswas sir: Can you share the details of how if his life changed due to the pain he's experiencing since last 4 months?
[9:52 PM, 5/22/2021] Avinash Kumar Gupta: Having continuous pain and difficulty in sleep, but life is going as it was earlier.
[9:52 PM, 5/22/2021] Dr. Rakesh Biswas sir: You mean vitamin d therapy leading to chest pain as an ADR?
Share some literature around that 👍
[9:52 PM, 5/22/2021] Dr. Rakesh Biswas sir: No change in majority of his life activities?
[9:54 PM, 5/22/2021] Avinash Kumar Gupta: He got an xray - no findings.
He is interested to get a CT in hope that it may help.
He is not going gym due to lockdowns and not able to do exercise at home neither he wanted, he wanted to wait for gyms to open again. For other regular activities he is able to do everything but with pain.
[9:56 PM, 5/22/2021] Divya PharmD, md: No sir ... We focus therapy based on the etiology also right ...
U have mentioned as he was under Vit.D supplements and so the pt. might be deficit of Calcium...
.
Managing Vit.D to normal level may improve condition sir .. Along with physical therapy / exercise may ease I hope
[9:58 PM, 5/22/2021] prof: Chiropractic is more effective
[9:58 PM, 5/22/2021] Avinash Kumar Gupta: Normal
[10:01 PM, 5/22/2021] Dr. Rakesh Biswas sir: How long is he not being able to go to the gym? 4 months?
[10:01 PM, 5/22/2021] Avinash Kumar Gupta: No gym since 5 months. And pain since 4 months.
[10:02 PM, 5/22/2021] Avinash Kumar Gupta: Pain increased since 2 months.
[10:03 PM, 5/22/2021] Divya PharmD, md: Sir ... May I know the diagnosis confirmatory parameters for this case ?
[10:05 PM, 5/22/2021] Dr. Rakesh Biswas sir: Although logical the relationship between drug intervention and efficacy of outcome may not be that logical and linear and that is why we need scientific experimental evidence in the form of randomized controlled trials.
Can you share any such randomized controlled trial evidence for vitamin d administration being beneficial for those with incidentally detected vitamin d deficiency (incidentally do also review the literature on the true incidence of vitamin d deficiency in India. Is it because of a high rate of overtesting?).
[10:06 PM, 5/22/2021] Dr. Rakesh Biswas sir: That's what we are trying to find out. We are trying to find out the cause of his chest pain
[10:06 PM, 5/22/2021] Divya PharmD, md: Sure sir
[10:06 PM, 5/22/2021] Divya PharmD, md: Ok sir
[10:09 PM, 5/22/2021] Divya PharmD, md: Sir ... Have u verified other symptoms incase it might be due to GI disease like PUD / GERD ...
[10:11 PM, 5/22/2021] Divya PharmD, md: The pt. sometimes may not differentiate acid reflux and chest pain ...
[10:26 PM, 5/22/2021] Dr. Rakesh Biswas sir: 👍yes as per Avinash's history do you think he could be having GERD?
What are the two symptoms most specific for GERD?
[10:31 PM, 5/22/2021] Divya PharmD, md: Sir I thnk we need few more details to for GERD ... Like after eating does he feels bloating / acid reflux ...
Especially when the pt. fall in bed after eating he may feel chest ache due to acid backflow ... Even upto esophagus ...
Abdominal pain and Bloating like symptoms have to be clarified sir
[10:35 PM, 5/22/2021] Dr. Rakesh Biswas sir: 👍Hope Avinash clarifies these
[10:35 PM, 5/22/2021] Divya PharmD, md: Yes sir ... 🙂
[10:36 PM, 5/22/2021] Avinash Kumar Gupta: None above present. I haven't added negative history in much detail.
[10:36 PM, 5/22/2021] Divya PharmD, md: But no significant acidity or gastric issues
[10:37 PM, 5/22/2021] Divya PharmD, md: Yes
[10:38 PM, 5/22/2021] Avinash Kumar Gupta: Yes. None
[10:52 PM, 5/22/2021] Dr. Rakesh Biswas sir: It's the same patient reports? When did he have this CT scan done? I thought he was asking our previous physician to advice CT scan?
[10:53 PM, 5/22/2021] Avinash Kumar Gupta: Yes sir
[10:53 PM, 5/22/2021] Avinash Kumar Gupta: He got it done 3 months back
[10:53 PM, 5/22/2021] Avinash Kumar Gupta: Still he had hopes from another CT. (May be because he don't know about MRI😊)
[11:11 PM, 5/22/2021] Dr. Rakesh Biswas sir: Need to know more about that episode of pancreatitis. What symptoms happened at that time?
[11:11 PM, 5/22/2021] Avinash Kumar Gupta: Thanks sir.. Will find and update here
[4:35 AM, 5/23/2021] Avinash Kumar Gupta: Differentials - costochondritis, tietze syndrome, chronic pancreatitis