42M Palpitations intermittent 3 years CG PaJR
Patient Advocate: Hello
Chest Mein Halka Sa pen Hai Aur kamjori Bhi lag raha hai sir Ke Piche gardan Mein Thoda Sa Halka Dard Hai
Pichhle 2 Hafte se ΰ€ΰ€-ΰ€ΰ€ ghante mein urin ho raha hai
Pichhle 2 sal pahle Aisa Hi chest pen hokar Dil Ki Dhadkan 28 bar per minut ho gaya tha same Vaisa hi Abhi Bhi lag raha hai
Jiska treatment hyderabad Hospital mein kiya gaya tha
Participant: Patient getting slight pain in chest, feeling week, back if the neck also there is pain and discomfort
Participant: Last 2 weeks patient is getting urge for urinations
PaJR PHR Moderator: Uska discharge summary share kijiye taki IP number dikhe par patient ka naam na dikhe
Participant: 2 years back patient has same symptoms hear rate came down
Patient Advocate: Sar vah do sal pahle admit hua tha to uska discharge paper mil Nahin raha hai main aaj dhundhne ka koshish kiya tha
PaJR PHR Moderator: He needs to collect his 24 urine volume as well as the total 24 hour water he's taking and share it with us
Participant: Patient visited hyderabad hospital then
PaJR PHR Moderator: Kal subah yahan yaad dilana. Hum college computer mein dhoondenge
Patient Advocate: Okay sar
Participant: Aap paani kitna pee rahe hai ek din me
Participant: Andaaz se
Patient Advocate: Subah Se Raat Tak 3 litre Pita hun
Participant: Patient is a sub contractor working on hill top he is experiencing dryness of throat, urge to drink water, low heart beat, dizziness
PaJR PHR Moderator: Pyas aane par peete hain ya waise hi?
Patient Advocate: Sirf Pyas lagne per Hi Pita hun
PaJR PHR Moderator: Kal subah sahi se 24 ghanta naap kar peejiyega aur pishab bhi naap kar batayiyega 24 ghante ka
Patient Advocate: π
Participant: π
Patient Advocate: Sar ismein Jo medicine likha injection usko lena hai ki nahin
Participant: Nahin abhi nahin
PaJR PHR Moderator: Nahin
Patient Advocate: Ji
Patient Advocate: Sir koi bat hai kya
Sar cardiologist ko jode kya
PaJR PHR Moderator: Locally dikha sakte hain cardiologist ko
Patient Advocate: Sir yahan nahi hai ya to raipur me hai
PaJR PHR Moderator: Thik hai. Raipur mein hi dikha lijiye
Participant: Sir patient waiting for you near OPD π
PaJR PHR Moderator: Yes saw him
Saw him for the first time as a patient's relative in 2019
Then in early 2020 after he had a head trauma and was admitted here
He had taken loan for his treatment (possibly before getting admitted with us) and the loan sharks forced him to again get admitted in 2021 with stress! Perhaps seen by @Paticipant at that time.
This time also similar symptoms suggestive of stress with no organic objective findings
PaJR PHR Moderator: Complains of nuchal and shoulder pains since 2 months.
Participant: please send him to physiotherapy for neck, shoulder and back strengthening exercises
Participant: Ok sir
PaJR PHR Moderator: Let's see his yesterday's interview details from the psy. Please ask someone to send his file to the OPD @Participant
Participant: Ok sir
Patient Advocate: π
Psy 2: they missed his head injury history! @Participant remember the head injury paper you wrote with them?
Should have added @Narmeen Shah here earlier as she could have prepared this case report also by talking to this patient telephonically @Patient Advocate
@Participant may be able to share all that has transpired in this group
Patient Advocate: Sir chest paine ke liye bhi dawai likhwadona
PaJR PHR Moderator: @Participant can add tablet amitriptyline 10 mg one hour before dinner in his discharge
Participant: Ok sir
PaJR PHR Moderator: @Participant didn't share the older discharge from 2020 yet. @Participant please collect his signed informed consent for the case report by @Narmeen Shah before he leaves. The forms are in ICU or with Participant.
PaJR PHR Moderator: This is the EMR summary for this admission written by Participant π
Age/Gender : 42 Years/Male
Discharge Type: Relieved
Admission Date: 24/11/2024 05:29 AM
Diagnosis:
ACID PEPTIC DISEASE TINEA CRURIS
TOBACCO DEPENDENCE SYNDROME
Case History and Clinical Findings
C/O CHEST PAIN SINCE 3 DAYS
HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS AGO THEN HE DEVELOPED CHEST PAIN INSIDIOUS ONSET BURNING TYPE NON RADIATING ASSOCIATED WITHJ CHEST HEAVINESS
NO C/O PROFUSE SWEATING,SOB NOT A/W NAUSEA,VOMITING
H/O BELCHING NO H/O TRAUMA
NO H/O HEAVY WEIGHT LIFTING
NO H/O WEIGHT LOSS/WEIGHT GAIN
H/O SIMILAR COMPLAINTS 3 YEARS AGO PAST ILLNESS:
N/K/C/O DM,HTN,CVA,CAD,EPILEPSY,TB,THYROID DISORDERS PERSONAL HISTORY:
APPETITE: NORMAL
BOWEL AND BLADDER: REGULAR ALLERGIES: NONE
ADDICTIONS: ALCOHOL OCCASIONALLY
GENERAL EXAMINATION:
NO PALLOR ICTERUS CYANOSIS CLUBBING LYMPHADENOPATHY OEDEMA BP: 110/70 MMHG
PR:56 BPM RR: 18 CPM
TEMPERATURE:98 F SPO2: 98% AT RA GRBS:101 MG/DL
CVS: NO THRILLS, S1S2 +, NO MURMURS NO ADDITIONAL SOUNDS HEARD
APEX BEAT FELT AT LEFT 5TH ICS JUST LATERAL TO MID CLAVICULAR LINE RS:
CHEST SHAPE SYMMETRICAL
NO SINUS,DISCHARGES,SCARS,SKIN CHANGES BAE+,NVBS, NO ADDED SOUNDS
PER ABDOMEN: SOFT, NON TENDER, NO ORGANOMEGALY, NO ABDOMEN DISTENSION CNS : NFND
PSYCHIATRY REFERRAL DONE ON 25/11/24 I/V/O STRESS DIAGNOSED AS TOBACCO DEPENDENCE SYNDROME ADVISED:NICOTINE GUMS 2MG PO TID/SOS
T. CLONAZEPAM MO 0.5MG PO/SOS
DERMATOLOGY REFERRAL DONE ON 25/11/24 I/V/O ITCHY SKIN LESIONS ON B/L BUTTOCKS DIAGNOSED AS TINEA CRURIS
ADVISED: CAP. ALCROS 100MG PO BD X 2WEEKS LULIFIN CREAM L/A BD X 2 WEEKS
TAB. TECZINE 5MG PO OD X 1 WEEKS KETO SOAP
Investigation
SERUM ELECTROLYTES (Na, K, C l)SODIUM 137 mmol/L POTASSIUM 4.2 mmol/L CHLORIDE
102 mmol/L CALCIUM IONIZED 1.18 mmol/L Serum Creatinine 0.7 mg/dl
HEMOGRAM
HAEMOGLOBIN 12.4 gm/dl TOTAL COUNT 5,700 cells/cumm NEUTROPHILS 56 % LYMPHOCYTES 34 %EOSINOPHILS 02 % MONOCYTES 08 % BASOPHILS 00 % PCV 38.3 vol % M C V 96.2 fl M C H 31.2 pg M C H C 32.4 %RDW-CV 11.2 % RDW-SD 40.2 fl RBC COUNT 3.98millions/cumm
PLATELET COUNT 2.30 lakhs/cu.mm SMEAR
RBC Normocytic normochromicWBC With in normal limitsPLATELETS Adequate in number and distribution HEMOPARASITES No hemoparasites seenIMPRESSION Normocytic normochromic bloodpicture
LIVER FUNCTION TEST (LFT)Total Bilurubin 1.00 mg/dlDirect Bilurubin 0.20 mg/dl SGOT(AST) 21 IU/LSGPT(ALT) 21 IU/L ALKALINEPHOSPHATASE88 IU/LTOTAL PROTEINS 6.8 gm/dlALBUMIN
4.68 gm/dlA/G RATIO 2.21RBS 130 mg/dl
2D ECHO: TRIVIAL TR ,NO PAH,TRIVIAL AR,NO MR NO RWMA. NO AS/MS
GOOD LV SYSTOLIC FUNCTION
NO DIASTOLIC FFUNCTION,NO PE/LV CLOT
Treatment Given(Enter only Generic Name)
T. PAN 40MG PO OD
TAB TEIZINE 10MG PO OD LULIFIN CREAM L/A BD
SYP. SUCRAL O 10ML PO TID NICOTINE GUMS 2MG PO TID/SOS MONITOR VITALS AND INFORM SOS
Advice at Discharge
T. PAN 40MG PO OD
T. AMITRIPTYLINE 10MG 1 HR BEFORE DINNER TAB TECZINE 10MG PO OD
SYP. SUCRAL O 10ML PO TID NICOTINE GUMS 2MG PO TID/SOS CAP. ALCROS 100MG PO BD X 2WEEKS LULIFIN CREAM L/A BD X 2 WEEKS TAB. TECZINE 5MG PO OD X 1 WEEKS KETO SOAP
Follow Up
FOLLOW UP TO GM AND DERMATOLOGY OPD AFTER 2 WEEKS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: ____________. For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language..
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date Date: 26/11/24 Ward: MMW Unit:III
@Participant: Sir, patient had already left.
PaJR PHR Moderator: @Narmeen Shah can you guide @42M Palpitations PA as to how to download the signed informed consent and sign it and share it with you after scanning before you can prepare his case report
Narmeen Shah: Sure sir π
27/11/24
PaJR PHR Moderator: This is his previous admission EMR summary that will also go into the case report:
AGE: 42Y/M
DOA:28/06/2022;
08:41 AM
Diagnosis
1.MICRO VASCULAR ANGINA WITH GENERALISED ANXIETY DISORDER .
2.NON ULCER DYSPEPSIA .
3.TOBACCO POUCH KERATOSIS ON LEFT LOWER VESTIBULAR REGION WITH CHRONIC GENERALISED GINGIVITIS WITH LOCALISED PERIODONTITIS.
Case History and Clinical Findings
PATIENT CAME WITH C/O RETRO STERNAL CHEST PAIN SINCE 4 DAYS .
HOPI: Patient WAS APPARENTLY ASYMPTOMATIC 2YR BACK AND HAD A INJURY TO RT TEMPORAL REGION DUE TO FALL FOR WHICH CT BRAIN WAS DONE AND SHOWED AN HEMORRHAGE FOR WHICH HE TOOK MEDICATION TAB .TeGRETOL 100MG FOR 3 MONTHS AND STOPPED.NOW SINCE 4 DAYS BACK AND DEVELOPED CHEST VPAIN WHICH CRUSHING TYPE NON RADIATING AND DOESNT RELIEVE ON MEDICATION .INCREASES ON ACTIVITY .RELIEVES ON REST .ANXIETY +NT .NO PALPITATION ,DYSNEA,VOMITINGS,SWEATING.
PAST HISTORY : NOT K/C/O HTN /DM/CVA/CAD/ASTHAMA.
PERSONAL HISTORY : DIET -MIXED
APPETITE NORMAL
SLEEP ADEQUATE
BOWEL AND MICTURITION -NORMAL .
ADDICTION-PATIENT HAD AN HABIT OF CHEWING THAMBAKU AND PAN SINCE 12YRS .
FAMILY HISTORY :NOT SIGNIFICANT
SYTEMIC EXAMINATION: O/E PT C/C/C
AFEBRILE
PR 78BPM
BP 120/70MMHG
CVS- S1S2+
RS -BAE +
CNS- NAD
P/A- SOFT AND NON TENDER.
COURSE IN THE HOSPITAL: PATIENT CAME WITH C/O CHEST PAIN ,ECG AND BASIC INVESTIGATION WAS DONE.ECG SHOWED NORMAL SINUS RHYTHM AND WAS MANAGED CONSEREVATIVELY .PATIENT WAS KEPT ON OBSERVATION AND VITALS MONITERED . 2D ECHO WAS DONE ,NO RWMA DETECTED,GOOD LV/RV FUNCTION ,EF 65%. PT HAD FOOD LODGEMENT IN TOOTH AND ULCER IN MOUTH AND YELLOWISH DISCOLOURATION OF TEETH . PATIENT WAS REFFERED TO DENTIST I/V/O ORAL ULCER AND YELLOWISH DISCOLOURATION OF TEETH .DENTIST HAS REVEWIED THE CASE AND INVESTIGATION HAVE BEEN DONE. PROVISOINAL DIAGNOSIS OF TOBACCO POUCH KERATOSIS ON LEFT LOWER VESTIBULAR REGION WITH CHRONIC GENERALISED GINGIVITIS WITH LOCAL PERIODONTITIS WAS DONE AND MANAGED CONSERVATIVELY.DEEP SCALING DONE ON 1/7/22 AND ADVICED TO REVIEW AFTER 15 DAYS TO DENTAL OPD .
Investigation: ECG NORMAL SINUS RHYTHM
Treatment Given(Enter only Generic Name)
TAB .ULTRACET 1/2 TAB QID
TAB.CLONAZEPAM 0.2 MG PO/BD
OINT.RETINOL A 0.025% ON LESION
Advice at Discharge:
1.TAB .ULTRACET 1/2 TAB QID FOR 4DAYS
2.TAB. CLONAZEPAM 0.2MG PO/BD FOR 7DAYS
3.OINT . RETINOL A 0.025% ON LESION FOR 15DAYS
4.HEXIDINE MOUTH WASH
5.STOLIN GUM PAINT
6.THERMOCELE PASTE
Follow Up:
REVIEW AFTER 15 DAYS TO DENTAL OPD FOR FURTHER FOLLOWUP
When to Obtain Urgent Care:
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care:
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: ___________. For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
S IGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date Date:4/7/2022 Ward:male medical ward Unit: 5
20/06/25
PaJR PHR Moderator:
Came from Chattisgarh:
Reviewed Today in OPD
PaJR PHR Moderator: Just reviewed his case report with EMR summaries from 2022!
Unexplained chest pain with anxiety symptoms assumed to be microvascular angina!
@Participant can the LLM dive deep into the case report content and offer it's inputs.
@Participant @Narmeen Shah can we update this case report?
Participant: This case report was done by Narmeen Mam from the beginning
PaJR PHR Moderator: Yes just a mirror blog similar to web archiving with plus features of updating.
More our team members host each other's cases in their own portfolios the better it is
Participant: Based on the provided WhatsApp snippet and your request, here's a structured approach to updating the case report and leveraging LLM (like myself) for deeper analysis:
---
### *Step 1: Key Clinical Context from Snippet*
- *Patient Origin*: Chhattisgarh (potential geographic health factors)
- *Presentation*: Unexplained chest pain + anxiety symptoms
- *Prior Diagnosis*: Suspected microvascular angina (non-obstructive coronary arteries)
- *Timeline*: Case reviewed in 2022, now revisited in 2025 (3-year gap)
---
### *Step 2: Critical Gaps Needing Update*
To refine the diagnosis/management, collaborate with *@Participant, *@Participant*, and *@Participant** to gather:
1. *New Diagnostic Data*:
- Recent cardiac tests (updated angiogram, cardiac MRI, stress test)
- Biomarkers (high-sensitivity troponin, CRP)
- Anxiety/depression screening (e.g., GAD-7, PHQ-9 scores)
2. *Treatment Response*:
- Medications trialed (e.g., beta-blockers, CCBs, antidepressants)
- Lifestyle/psychological interventions (CBT, relaxation therapy)
3. *Rule-Out Confounders*:
- Gastroesophageal reflux (GERD), musculoskeletal pain, autoimmune disorders
- Social stressors (e.g., financial/occupational triggers)
---
### *Step 3: LLM Deep-Dive Strategy*
Once the case report/EMR data is shared, I can:
#### *A. Reanalyze Historical Data (2022)*
- Identify overlooked patterns in symptoms/test results
- Cross-reference with *microvascular angina guidelines* ([ESC 2023](https://doi.org/10.1093/eurheartj/ehad248)):
> Key criteria: Recurrent angina, ischemic ECG changes, no coronary obstruction, impaired coronary flow reserve.
- Assess anxiety comorbidity: Is it causative or secondary?
#### *B. Current Clinical Questions to Address*
1. Is microvascular angina still plausible?
- LLM can compare 2022 vs. 2025 data for progression.
2. Could this be *INOCA* (Ischemia with Non-Obstructive Coronary Arteries) or *mental health-driven*?
- LLM can review symptom-anxiety temporal linkage.
3. Treatment optimization:
- First-line: Ranolazine/Trimetazidine?
- Anxiety: SSRIs vs. non-pharmacologic options?
#### *C. Evidence-Based Insights*
- *Microvascular Angina Pitfalls*:
> 30-50% of INOCA cases have cardiac microvascular dysfunction; anxiety doubles recurrence risk ([JACC 2022](https://doi.org/10.1016/j.jacc.2022.03.366)).
- *Anxiety-Chest Pain Link*:
> Autonomic dysregulation can mimic ischemia via vasospasm/tachycardia ([Psychosom Med 2023](https://doi.org/10.1097/PSY.0000000000001175)).
---
### *Step 4: Action Plan for the Team*
1. *@Participant / @Participant*:
- Update case report with:
- Latest test results (2023-2025)
- Medication adherence/side effects
- Psychosocial assessments
- Share de-identified EMRs/text summaries for LLM analysis.
2. *@Participant*:
- Consider:
- *Coronary reactivity testing* (if not done)
- *Holter monitoring* for arrhythmia-anxiety correlation
- *Multidisciplinary consult* (cardio-psychiatry interface)
3. *LLM Output*:
- Provide differential diagnoses
- Generate a timeline visualization (symptoms/tests/treatments)
- Suggest evidence-based management algorithms
---
### *Final Recommendations*
- *If anxiety is dominant*: Trial escitalopram + cardiac rehab (proven in [IMPACT trial](https://doi.org/10.1001/jamacardio.2021.1045)).
- *If cardiac pain persists*: EndoPAT testing for endothelial dysfunction.
- *Urgent red flags*: Syncope, nocturnal pain, troponin elevation → rule out MINOCA.
*Next Step*: Share the full case report/EMR data here for LLM deep-dive! I’ll await the updated details. π©Ίπ‘
PaJR PHR Moderator: It's here https://narmeenshah.blogspot.com/2024/12/42m-palpitations-intermittent-3-years.html
Participant: Based on the comprehensive case details spanning 2022-2024, here's a clinically structured analysis and management roadmap:
---
### *Critical Clinical Patterns & Red Flags*
1. *Cardiac-Anxiety Interface*
- Recurrent chest pain (burning/non-radiating) with normal coronaries (2D Echo 2022/2024)
- *Bradycardia episodes*: HR drop to 28 bpm (2022) and current HR 56 bpm
- Anxiety-driven admissions (2021/2024) + loan-related psychosocial stress
2. *Autonomic Dysfunction Clues*
- New urinary frequency (hourly ×2 weeks) + dry throat + polydipsia (3L/day)
- Neck/shoulder pain + dizziness
- *Inconsistency*: Thirst only when prompted ≠ psychogenic polydipsia
3. *Tobacco & Organic Complications*
- Tobacco pouch keratosis (2022) → current tinea cruris
- Amitriptyline added (2024) for pain modulation
---
### *Diagnostic Re-Evaluation Priorities*
#### *A. Cardiac Workup*
- *Exclude conduction defects*:
> 24h Holter monitoring (bradycardia + dizziness)
> Tilt table test (autonomic dysfunction)
- *Reassess microvascular angina*:
> Coronary flow reserve (CFR) via transthoracic Doppler echo
> High-sensitivity CRP + IL-6 (inflammation markers)
#### *B. Endocrine/Metabolic*
- *Diabetes insipidus?*
> Serum/urine osmolality + water deprivation test
- *Adrenal insufficiency?*
> AM cortisol + ACTH stimulation test (fatigue, hypotension)
#### *C. Neurological*
- *Post-head trauma sequelae* (2020 temporal hemorrhage):
> Repeat neuroimaging if persistent dizziness
> Autonomic testing (sudomotor, Valsalva)
#### *D. Psychiatry Interface*
- *Differentiate*: Cardiac vs. somatic symptom disorder
> PHQ-15 (somatization screen) + GAD-7
- *Tobacco cessation efficacy*: Verify nicotine gum adherence
---
### *Immediate Management Adjustments*
| *Domain* | *Action* |
|---------------------|----------------------------------------------------------------------------|
| *Cardiac* | Hold Ξ²-blockers (worsens bradycardia); consider ivabradine if angina confirmed |
| *Pain Control* | Continue amitriptyline 10 mg HS (neuropathic pain modulator) |
| *Autonomic Sx* | Fluid log strict input/output + electrolytes (exclude SIADH) |
| *Dermatology* | Extend antifungal (Alcros) to 4 weeks (recurrent tinea) |
| *Addiction* | Add varenicline (if nicotine gum fails) + CBT |
---
### *Long-Term Strategy*
1. *Multidisciplinary Team*:
- *Cardiology + Psychiatry*: Co-manage INOCA-anxiety overlap
- *Endocrinology*: Rule out hypothalamic-pituitary axis dysfunction post-head injury
- *Physical Therapy*: Cervical strengthening (chronic neck pain)
2. *Patient Education*:
- *Bradycardia red flags*: Syncope, confusion → ER immediately
- *Tobacco-mood link*: Stress role of cessation in symptom reduction
3. *Case Report Focus* (for @Participant):
> "Autonomic Dysfunction in Post-Traumatic Microvascular Angina: A 5-Year Journey"
---
### *Why This Approach?*
- *Bradycardia* is inadequately explained by anxiety alone → needs cardiac & autonomic workup
- *Urinary frequency + polydipsia* may indicate DI (head injury complication)
- *Amitriptyline* covers: neuropathic chest pain, anxiety, and migraine prophylaxis (post-trauma)
*Next Step*: Schedule Holter + endocrinology consult before 2-week follow-up.
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