Data analysis to find simple investing strategy

Data analysis to find a simple investing strategy for decent returns by testing how well the stock market follows the Pareto principle.

Data source - (Dec - 30 - 2021)  5-year return on equity (ROE) data exported from the paid version of tickertape.in for the companies listed in Nifty 500. 

Histogram for visualization showing number of companies vs percentage return.

link to pdf document with high resolution image- https://docs.google.com/spreadsheets/d/e/2PACX-1vSSRiYdSBFANIomorItjshvW-l4Iyrg1zaQlvvesnN2qd6eEkxG40jdoIDetGJfg6dD0EfDRiOJq5f9/pub?output=pdf

Mean	14.6%
Median	14.88%
Standard Deviation	12.88%
Above 28.9%	37	7.4%
Below 5%	78	15.6%
between 5% - 28.9%	386	77%
Conclusion	Pareto Principle can be followed. 20% losers, and 80% winners in the portfolio can give an average 15% annual return in long term investing.

Optimization can be done based on various factors but that may not be necessarily useful. 

For a hypothetical case of having the highest return possible on a portfolio of 15 stocks containing only top performers is 53% but surely finding such multi-baggers may be very difficult and even on making a dedicated effort on analysis only 1-2 such may be found for a portfolio of 15 stocks.

Note - Nifty 50 ETF gave 16% ROE (5 Y Avg)

PS - when insurance companies or big pharma may be working on insurance premium or drug pricing etc, data for normal distribution in a similar way on a representative population may become highly useful. Use and harm because of data depends on the purpose it's used for i.e. to maximize profit or to maximize access or somewhere in the middle. 

Impact of Open-Access De-identified case records

While current efforts are towards adoption and interoperability to enable patient data access 24*7 globally as longitudinal record for their life journey, there isn't any technologically feasible and safe way but only debates and tiny projects around open access de-identified data which someday may get utilized at the global scale (even useful if scale is not so huge). The low hanging fruit may be firstly enabling the access to all research papers globally, or all data of clinical trials for better critical appraisal or atleast reporting of outcomes of all trials including those with negative outcomes. The most urgent goal is surely global equitable access of covid vaccines. The paragraph below is taken from project working on a real world scenario to alleviate human suffering with help of open access de-identified data, not in healthcare directly neither global scale but still surely useful. 

"In almost every state, courts can jail people who fail to pay fines, fees, and other court debts—even those resulting from traffic or other non-criminal violations. While imprisoning someone for failing to pay a debt remains illegal on paper, these aggressive debt-enforcement tactics have led to the de facto reemergence of debtors’ prisons. Many believe that thousands of people across the country are jailed each year for unpaid fines and fees, but a dearth of data has made it difficult to rigorously assess and curb modern-day debt imprisonment practices. To address this data gap, we’re compiling an extensive database documenting debt imprisonment. Ultimately, we will anonymize the data and publish them for researchers, civil rights advocates, law enforcement officers, and other criminal justice stakeholders." 

ref - https://law.stanford.edu/event/stanford-computational-policy-lab-debtors-prisons-project/ 

Debtor's Prison - https://en.wikipedia.org/wiki/Debtors%27_prison

Hopefully someday open access de-identified health data will help others to get freedom from the disease prison.

Cardiology - NNT visualization

NNT - Number needed to treat

explanation here - https://www.thennt.com/thennt-explained/

ref for data - https://www.thennt.com/home-nnt/

The NNT data available on thennt.com for cardiology speciality, visualized on logarithmic scale to give insight about various interventions. No bar drawn in case of none helped by the drug in given scenario based on available evidence. Purpose for drawing the visualizations was to understand the realistic range/expectation of effects from drugs. 

Insights:

- 18 out of 48 have no effect.

- 3 have NNT 5 of less

- 6 have NNT 6 to 10

- 12 have NNT 11 to 50

- 6 have NNT 51-100

- 4 have NNT above 101

- 1 have NNT above 1500 i.e. Aspirin to prevent first heart attack or stroke.

fig 1 - image

fig 2 - Original image

download excel sheet ->

https://docs.google.com/spreadsheets/d/e/2PACX-1vQ7aN8_Ro9A5AAq1mbqh8nMon4EAPE40S5N2He-6HLhU7Giq1t3yqw782E-wSgt2JbVrKsxhDmMthlL/pub?gid=0&single=true&output=pdf

sorted list ->

OpenEHR with FHIR for more power

 FHIR - Fast Healthcare Interoperability Resources is getting adoption at tremendous speed and hence enabling scope for successful nationwide interoperability while also being easy to get started and implement. OpenEHR also solves the interoperability challenge as one of its features. While FHIR adoption and ecosystem is maturing in India, interoperability problem may be best tackled with it.

Combining OpenEHR with FHIR and clinical terminologies (eg. LOINC, SNOMED CT) is a possibility to build more powerful electronic medical records because of the Archetypes in OpenEHR. 

"Archetypes define the possible clinical content, representing a model that originates from actual clinical practice. Archetypes have a governance boundary around them, essentially representing a clinical sign off that can be used to support the idea of a clinical data standard. One or more archetypes can then be used in a template that represents a specific clinical use case. A simple example could be the development of a Body Mass Index (BMI) app. In order to achieve this, we need three principle archetypes to capture height, weight and the BMI itself. The benefit of using these standard archetypes is that they can also be inserted into other templates that require the same clinical data. And when that data is stored in a common way, it can be queried and reused, reducing the burden of repeated data entry." 1

"Reuse of data  - A key attribute of any clinical data repository is its ability to facilitate reuse for additional clinical requirements and for audit and reporting purposes. The Archetype Query Language exists to support this. AQL provides a means of performing queries on the CDR for individual or multiple records at either the patient or archetype level, maintaining data provenance and exporting for more advanced analysis where needed."1

While clinical terminologies help in analysing data, AQL provides another dimension of data analysis i.e. at patient/archetype level in much easier way.

fig 1 - example archetype

Conclusion -

Design choice of :

- using FHIR for Interoperability (across the globe). 

- using OpenEHR Archetypes for data storage (writing to database and reusing in templates)

- AQL on CDR and clinical terminologies for more powerful analytics.

fig 2 - FHIR + OpenEHR

references -

1- https://echalliance.com/what-is-openehr-and-why-is-it-important/

fig - https://ckm.openehr.org/ckm/archetypes/1013.1.3574/mindmap

fig - https://www.youtube.com/watch?v=biEXVRzjWmw&t=841s&ab_channel=openEHR

18 M FOU with Seizure

18 year old male, he had his first seizure at the age 5 when he was having High fever. By the age of 18 now he had 10 such episodes of seizure. 

He gets this high fever every 3-6 months and temperature goes to 103-104 degree fahrenheit. He had adenoidectomy and Tonsillectomy 6 years back to prevent these recurring fever but it didn't help. Currently he is having similar fever again. 

For his seizure he had
- Valparin - 2008
- Tegrital-2012
- Levipil-2013
and currently he takes Levipil (levetiracetam) and since it started there were no more seizure episodes.
He used to get hospitalized after seizure episodes and neck rigidity used to be there so csf analysis was done which had nothing significant, neither any pathology found in MRI and EEG. 
Severe Proteinuria happens during hospitalization phase which goes back to normal on recovery.
Usually after 24 to 48 hrs of fever seizure happens.
Sodium Valporate was taperd and stopped in 2010 ,but 2 months after that  he again developed seizures without fever, Again in 2013  levipil  was stopped but the following day he developed an episode of so the dosage was increased and we were advised to continue  the medication further. These were the two instances when he got the episode without fever

- CRP 273.6 mg/L

- Total WBC count 15500

- Pro-calcitonin - 5.44

- Dengue - nagative

- Malaria - negative

- Protein in urine - +++

- 24 hr urine protien - 2488.5 mg/24hr (urine vol. 1500 ml)  

- Random urine protien - 165.9

Current Fever chart - 

Timeline - 

These pics are a list of differentials from Isabel software: with simple query, not having much clinical history details

this is again isabel software output but after detailed clinical history

Query Details

Age: Young Adult 17-29 yrs

Gender: Male

Pregnancy: Not-specified

Region: Southeast Asia

Query Text: apthous ulcers|fever of unknown origin|recurrent fever|back pain|proteinuria|tonsillitis|pharyngitis|seizures

Brucellosis INFECTIOUS DISEASES

Coronavirus INFECTIOUS DISEASES

Relapsing Polychondritis RHEUMATIC DISEASES

Infectious Mononucleosis INFECTIOUS DISEASES

Bartonella Infection INFECTIOUS DISEASES

Cytomegalovirus INFECTIOUS DISEASES

Lyme Disease INFECTIOUS DISEASES

Toxoplasmosis INFECTIOUS DISEASES

Non-Hodgkin Lymphoma NEOPLASTIC DISEASES

PFAPA Syndrome RHEUMATIC DISEASES

Steven-Johnson Syndrome DERMATOLOGY

HIV / AIDS INFECTIOUS DISEASES

Aplastic Anemia HEMATOLOGY

Inflammatory Bowel Disease GASTROINTESTINAL DISORDERS

Chikungunya INFECTIOUS DISEASES

Nephrocalcinosis NEPHROLOGY

Adult Still Disease RHEUMATIC DISEASES

Paraquat Toxicity / Parquat Lung TOXICOLOGY

Behcet's Syndrome RHEUMATIC DISEASES

Adrenal Neoplasms ENDOCRINE SYSTEM (red flag)

Enterovirus Infections INFECTIOUS DISEASES

Familial Mediterranean Fever RHEUMATIC DISEASES

Urinary Tract Infection NEPHROLOGY

Crohn Disease GASTROINTESTINAL DISORDERS

Fluke Infection INFECTIOUS DISEASES

Glomerulonephritis NEPHROLOGY

Nephrotic Syndrome NEPHROLOGY

Erythema Multiforme DERMATOLOGY

Hodgkin Disease NEOPLASTIC DISEASES

Neoplasms of the Kidney NEPHROLOGY

Tuberculosis INFECTIOUS DISEASES (red flag)

Aortic Aneurysm / Dissection VASCULAR DISORDERS (red flag)

SLE RHEUMATIC DISEASES (red flag)

Pemphigoid DERMATOLOGY

Common Cold / Nasopharyngitis RESPIRATORY DISORDERS

Heavy Metal Intoxication TOXICOLOGY

Relapsing Fever INFECTIOUS DISEASES

Osteomyelitis and Septic Arthritis INFECTIOUS DISEASES

Ulcerative Colitis GASTROINTESTINAL DISORDERS

Tularemia INFECTIOUS DISEASES

Acute Porphyria METABOLIC DISEASES (red flag)

        

Found pfapa to be the most probable diagnosis

AI

Quant is (ML/NN) Ai or at least Complex statistics when used for trading equity (and other instruments) by various methods. 

While it's all AI for price forecasting or HFT and taking decisions to even take trades itself. 

Some algo's failed badly while some adapted to the Black Swan event (financial market's disaster) making even that to be profitable event

Quant Bust 2020 https://arxiv.org/abs/2006.05632 

During the same black Swan event, various decision makers (doctors) overused CT scans for screening covid and overused various drugs for prophylaxis and treatment  while various guidelines and minimalist doctor's choose to go with symptomatology and conservative with home care unless needed otherwise. 

All medical decisions are between a minimalist-maximalist range, like in quants case it's between nowcasting and forecasting. How to find the balance or at least mostly be on the winning side? (at least on winning side may not be acceptable in medical decision making, as having minimum losses “do no harm” is the first important rule not to be missed when caring for a patient.) 

My understanding is, risk management is the key to finding the right balance which will help minimize losses, in quant field there are various objective tools for that, and same for the AI (and present day HI - human intelligence) is the way to go for medical decision making, so in medicine using techniques to find ADR, Anaphylaxis early and intervene early for them is important, evidence based rational use to prevent overtesting while also avoid undertesting and same way over treatment and under treatment. Also detecting suboptimal response of drugs in individual to find opportunity to replace with better alternatives if possible and even predicting what drugs may response better based on genotype/metabolomics/microbiome more easily and widely and other risk management strategies. These all are already known and application of these must increase towards finding the balance but still all these strategies together also may not guarantee a black swan / disaster in medicine but sometimes for the reward (clinical benefits) we have to take the remaining risk.

An example of black swans in medicine is PSA test misuse and many such examples exist there in medicine, which must be prevented by keeping strong focus on research (data generation , collection and analysis) for evidence and its appraisal.

The black swan / disaster in medicine may not be a sudden bad event, rather a bad practice not caught and corrected early.

Read full series here -

Trading and Medicine analogy (complexity, uncertainty, technology) - - https://classworkdecjan.blogspot.com/2021/07/trading-and-medicine-analogy-complexity_52.html

Frugal Immersive tech for healing chronic pain

IBS patient update - initially I was feeling bored and also wanted to change the topic rather than listen to tiny and probably useless points when she was speaking at very slow speed and I had to rush to read more for exam preparation but I tried keeping patience for sometime and what I got was something extremely amazing. She was slow as many stories she had lived like real life were going through her mind, where most if them were painful ones.. She was trying to evaluate them and make it in meaningful statement as how she is awake with eyes open but far far away from reality, feeling living in imagination which feels completely real and some moments are so slow as if time have stopped and this super slow scene stays there for long like many minutes or probably even an hour as she fails to keep track of real-time and these Stationary scenes gives her most amazing experience. Amazing in happy or sad way or what, can't explain clearly but may be can say the most powerful feelings. She detailed more about kind of stories she have lived but avoided giving much details, may be because fear of being judged, specially as I am a good friend now or also because risk of being Interfered as I needed to get back to study.. With details what beautiful thing I learnt was her "self hypnosis" Helping her to get big relief from chronic physical and emotional trauma and pain.

This show's a good opportunity for use of immersive tech like VR/AR/XR/MR against chronic pain (physical/emotional) management which has already started to become reality.

For a person practising self-hypnosis, it may be better to be guided by a professional who may help do better, safer and maybe less saddening ways. Interested to hear from trained clinical hypnosis practitioners or please share in comments if any relevant publications.

Self hypnosis = frugal, immersive (human tech).

Reply from RB sir -  Amazing write up 👏   Reflective self hypnosis is a great idea toward a new tech supported therapeutic tool 👍

even with lesser cost, why better healthcare?

https://www.numbeo.com/health-care/rankings_by_country.jsp

even with lesser cost, why better healthcare?

"It was recognized from the 1940s onwards that what was needed was a ‘health policy’ rather than a ‘disease policy’ as summed up by the director of the medical services Dr W. G. Wickremesinghe as early as 1945. Despite this ongoing acceptance of the benefits of preventive medicine the balance of government expenditure was overwhelmingly in favour of curative medicine as is the case in most other countries. One estimate of this balance in 1975 suggested that for every rupee spent on the curative sector only 12 cents was spent on prevention of disease and the promotion of health. This situation prompted the director of the Colombo Hospital to ask in 1970: “Was it more important to improve sanitation, nutrition, and health education and provide basic facilities for health and patient care for the masses of this country; or was it more important to go in for sophisticated and expensive programs like heart transplant units?” (Daily News, 3 Sept 1970). However, the hospitals were the visible symbol of Sri Lanka’s free health service and the symbol of modernity; switching resources to preventive public health was a highly politically contentious issue.

There were deep roots to the development of primary health care services in Sri Lanka and it represented at international level an example of what could be done without the levels of expenditure common in developed countries. Sri Lanka´s experience was an essential part of the debate on primary health care which took centre stage at international level in the 1970s. Furthermore, given the extent of its hospital based curative system it was also a perfect illustration of the limits of that model for low-income countries in the context of a burgeoning population and economic crisis. However, in the succeeding decades the challenge for Sri Lanka has remained that of finding the most effective route to reducing morbidity. This is now an ever more pressing priority with the demographic transition to an ageing population and the resulting double disease burden."

https://www.ncbi.nlm.nih.gov/books/NBK316260/

https://www.who.int/chp/chronic_disease_report/sri_lanka.pdf?ua=1

For India - Same scenario of double disease burden.

Trading and Medicine analogy (complexity, uncertainity, technology) - part 2

This graph shows a phenomenon called BTC dominance.. The way BTC graph moves (mid top)  will decide the way all other move making a similar pattern during fall but during rise they may not match so precisely though the effect remain in that too, only a few rarely at different time point show variation from this and there is mostly any external factor causing that variations. 

So if we consider all as course of intervention of various drugs eg. Anti-Hypertensive agents, the graph at center too which will be having dominance over all interventions effect will be "Lifestyle Intervention/modification"..

------------

The composite man , equivalent of big pharma in stock market (composite man is not necessarily bad or against a trader, its just another player with you in the market, playing for his/her own profit).. Luckily stock market have ways to understand it's game play, same as we have EBM combined with critical appraisal for understanding the real effect/benefit.

"Wyckoff created the idea of the Composite Man (or Composite Operator) as an imaginary identity of the market. He proposed that investors and traders should study the stock market as if a single entity was controlling it. This would make it easier for them to go along the market trends. In essence, the Composite Man represents the biggest players (market makers), such as wealthy individuals and institutional investors. It always acts in his own best interest to ensure he can buy low and sell high. The Composite Man’s behavior is the opposite of the majority of retail investors, which Wyckoff often observed losing money. But according to Wyckoff, the Composite Man uses a somewhat predictable strategy, from which investors can learn from." https://academy.binance.com/en/articles/the-wyckoff-method-explained

It's very interesting to notice that if someone focuses on very few stocks which have good fundamentals, they may make small but consistent profit, it's like the experienced doctor analogy who uses very few drugs for wide range of disease and still seen successful. Are they really successful? Or they are keeping safe way (for the patient) by giving small but sure profit than giving sometimes high gains and sometimes high losses.. In terms of investing they are successful as an important mantra is "never loose money", and same way in medicine too that "do no harm". When we become greedy wanting best possible there is scope of high benefit but high loss too.. 

Btw be it identifying wykoff method on a chart 📊 or critical appraisal for drug effects.. "We only see what we know"..

RB - 👏you are opening a new way of looking at medicine and it is just at the right place at the right time

Avi - Thanks sir!🙏

RB- Entering covid ICU and thinking of the stock options in the humans lying in front of me. The market stakes have come down since last two weeks with less people crashing (during the peak of 2nd phase of covid in India when delta variant created havoc.)

RB - Govt policy driven interventions (lockdown effect) to bring the market stakes down? 🤔

Avi - Better to say Swiss cheese model impact where govt. Is one among many factors.

RB - Integrative interventions 👏

RB - But what would be the analogy in terms of stock share trading?

Avi - As you are looking at population level, the analogy will also come at population level data and that is nifty / nifty 50 / sensex etc. Which are affected by overall effect on all stocks considered under these and also on how the market performs globally I.e. Dow, sgx (other countries)  etc. 

And the event at population level is a rare event of surge of cases of a particular disease in your facility and same seen globally and that may be analogous to a black Swan event... A black Swan event is a rare event that can not be predicted (a few say it can be sometimes) and they may lead to crash of a market , local / global and even at a smaller subset of local like your facility..but these rare events may happen in case of individual stocks or humans journey also eg. Mucoromycosis (not black swan technically in such case, just the system is an individual level).

"A black swan is an unpredictable event that is beyond what is normally expected of a situation and has potentially severe consequences. Black swan events are characterized by their extreme rarity, severe impact, and the widespread insistence they were obvious in hindsight." https://www.investopedia.com/articles/trading/11/black-swan-events-investing.asp

The covid pandemic may be a good example of black Swan event but not all Swiss cheese model failure based event may be black Swan.. Because black swans are rare events where are swiss cheese model also applies on common events eg. All Medical errors (they are very common)

One cool thing is, after the black Swan event happen and we analyse data in backdate it's easily possible to notice, but never possible to predict in future. Same happening in covid case hypes.. We easily point to crowded gathering events etc which lead to superspreader events..

The equivalent to medical errors in stocks can be, not analysing the data enough or well or not doing that with sufficient speed for decision making, not applying safety measures eg. Diversification, hedging, stop loss etc.. Not keeping personal psychology in control and away from bias, greed, fear.. And also the biases that are inbuilt in the analysis methods.

Sometimes it becomes important to break a few rules, sometimes being greedy may become useful.. Also misusing the safety Strategies are also a danger as putting stop losses too tight or too far, over diversifying etc. 

So right thing at right time in right quantity is important.. It's tough to be so right always so we loose alot in stock market... But if win rate is higher than loose rate by even 1% or exactly same then it's success because in first case there is some profit and in second there is no loss so profit may be in future.. But in Medicine we hide failures, they are not accepted easily as errors and so everyone only know success stories but nobody knows success rates..  

Interestingly in stocks if win rate is very less compared to loose rate but just keep check to keep loss sizes small and win sizes bigger then also its a profit overall.

RB - 👏 A large part of the literature in stock trade borrows from statistical theory. Good insights building up with this analogy 👏

Avi - [11:00 AM, 5/31/2021] Avinash Kumar Gupta: Yes sir. The winner and looser both apply stats and they both think they are right and it's even possible that the looser have better technology than the winner but when we see ratio, the lowest resource settings have win rate of approx 2% and rest 98% are small fishes to be eaten by the bigger ones, those having high resources. 

Various strategies and instruments are there in stocks and using some are very safe but low profit, some very risky but high profit and some in between and the resources required vary for them.. One aspect of such resources is capital -> For a good safety and good profit strategy the capital required is huge, for a high profit high risk the capital needed can be smallest size also but they wins may be very very less.. 

Having high resources brings different set of challenges that may never occur in case of small resource setups (retail investors) so not having high resources as mainly enough capital is a challenge but then more/ better skills, analytical capabilities, speed , etc comes into picture.. Procedural skills which are again learnt by doing both theory and practice.

recovering from another tough episode, which lasted shorter duration

De-identified writeup from client in his own words, published with consent. The client is self-learning psychology. In psychology its better to call client and not a patient afaik.

There is no better medicine than will power to come out from depression. But medicine are extremely important, all we loose is taking a month or 2 to find what suits and a few more month of continuation of a medication but what it helps is that may prevent from the extremes i.e. suicide.

depression changes the view of a person and force them to avoid seeing and appreciating the positives in life. But this is what most important to change to fight against , and even small small steps matter a lot.

sometimes people have questions like "why me" why this happened to me? or why not me, why something good didn't happened to me? and there is no answer to such questions except that all happen for some good and that good happen by being courageous, making plans and then efforts to make the good a reality.

long time back i had big troubles, and since then something like this has been my life track, I wish I had monitored it somehow but overall can generalize to this graph where the recent depressive state passed yesterday and i am hopeful to be in a good state for now and probably always.

(images taken from google image search)

Later update - on a psychiatrist visit

patient refused RFT and to continue any medication. sent this document for education - https://www.mind.org.uk/media-a/2966/bpd-2018.pdf

https://en.wikipedia.org/wiki/Dialectical_behavior_therapy

30 minute DIY app for patient's health monitoring

I have been working with an IBS patient who started following FODMAP diet and lifestyle modification to get relief from her 10+ years old IBS issues. Started helping her in health and data monitoring and understanding basic medical queries she was getting, and that's where simple tool like google sheets became very useful to record data and visualize. Later patient herself switched to taking data on paper and update it very rarely to the sheets, and I also realized updating an excel/google sheet was not the easiest way so tried developing an app.

Recently I also completed designing a framework for a community health project which is being executed by a small dedicated team on the ground somewhere in villages. Having the challenge to empower them with the right tools for delivering cost-effective evidence-based and well planned healthcare services with limited resources and technology-enabled ways, I got to experiment the same app development process and outcome is a beautiful and agile technique, sharing step by step tutorial below.

1) Use google forms to create a form having data that patients wish to monitor (data that matter for the patient) and also the data you as a care provider (family, friend, doctor) wish to monitor (and best to be evidence-based and if suitable then also a minimalist on this part).  ( 10 min. ) 

2) Create the google sheet with the form to collect responses and then go to google data studio and connect the sheet as a data source https://datastudio.google.com/  ( 2 min. )

3) Copy the code from github https://github.com/avi33tbtt/DIY-Med-App for a basic webview based android app and import project to android studio, and in the source file / java code just change the URL to your google form URL (avoid using shortened URL). ( 5 min. )

4) Build project and check on your device if it works then send apk to the patient. ( 2 min. )

5) when some data available, experiment with google studio to design your dashboard to help you visualize latest data in interactive way and even in real time. ( 11 min. )

App Screenshot

Dashboard Screenshot

contact me for any technical help to create yours or for any feedback to improve.

Avinash Kumar

avi33tbtt@gmail.com

*Data in the above image is shared with consent.

- Good to explore AppScript for creating web app using excel sheets for getting more power and be able to develop better DIY Tools and even capable to send data to a fhir server/EHR/EMR/PHR.

- These techniques are good for small scale implementation and I believe it to have capability of being highly patient-centric.

- Enable collect emails in form setting and filtering in the google studio dashboard for using same app for multiple users having similar requirements.

forwarded telemedicine case 24-M , chronic mild mid sternal pain

 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.

(amylase test on mid October 2020)

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

CBBLE in Pandemic

CBBLE - Case Based Blended Ecosystem - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6163835/

200 students from Final MBBS Part-2 , joined online learning session via WhatsApp for learning medicine and improving their problem-solving skills under the guidance of medicine professor Dr Rakesh Biswas at KIMS, Narketpally.

One of the elective student's (Avinash Kumar Gupta) case record of a complex patient was chosen to be shared and every student had to go through the case record, understand the details, learn around them for the patient's benefit and share their inputs as well as online e-log books.  The patient being an active learner and partner in her care was updated about the activity and she felt happy about being able to make an impact.

case - https://classworkdecjan.blogspot.com/2019/05/42-f-with-severe-regular-edema-with_17.html

Student's e-log books - https://detailedclinicalanalysis.blogspot.com/2020/05/online-learning-individual-patient-data.html 

sharing a few snippets from e-log books - 

1) https://vasishta175.blogspot.com/2020/05/patient-clinical-data-analysis.html 

Advice: Advanced  Diagnostic modality like Whole genome sequencing must be done.

Queries:- 

• She was diagnosed with hemolytic anemia but none of lab reports showed signs of hemolysis.
• Rapid fluctuations in her weight . Why is she swelling up on eating. ?
• Swelling which she has been complaining has not been explained properly. was is a kind of pitting or nonpitting type or is associated with any kind of rash 
• Her urge to salt intake inspite of her anhydrosis and decreased urination. Where is all her salt going if she is not sweating and urinating. There should be some sort of hypernatriemia. and why is it not happening.

2)  https://venumadhav171.blogspot.com/2020/05/case-of-42-yr-old-female-with-multiple.html

• SOME OF THE UNEXPLAINED ISSUES IN THIS CASE 
• Proper family history is not provided to relate her genetical prblems with the consanguinty of their parents marriage.
• Swelling which she has been complaining has not been explained properly. was is a kind of pitting or nonpitting type or is associated with any kind of rash etc.

So WHAT?

S - Strength - Its useful to do blended learning both offline and online, and as being asynchronous and in a network it helps to apply system 2 thinking in better way and engage together in learning from each other.

W - Weakness - Evaluation framework may not be easy and should be done based on student's effort, contribution and learning ouctomes.

O - Opportunities - Pandemic scenario is an opportunity to deliver better medical education without risking the lives of mentors and mentees.

T - Threats -  misconception of it being as good as bedside learning will be extremely wrong. Its a way to empower bedside learning to make an even better system, as well as an alternative in the pandemic scenario. 

Students submitted their e-log book links for evaluation.