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Atypical chest pain palpitations.

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24yo Male, 130kg - 174cm tall. No significant medical history in recent years.

Family History: Grandmother has angina. Distant family history (great grandfather) of heart disease due to rheumatoid arthritis.

Occupation: Security

Also possibly worth noting: Abnormal thyroid function test at age 12 years (was under stress at the time). MRI returned all clear. Nearly drown at 1 years old, without air - face down in pool for ~5 minutes. Adult CPR incorrectly performed (both hands on chest compressions). CPR successful, no noted adverse affects, though none tested for. Lived normal childhood, albeit with some pains on sides of ribs (ripping feeling) around age 8. [? Growing Pains]. Saw a GP around 10 years of age with pains in chest - he instructed me to strengthen the muscles by doing wall pushups.

History of drug abuse: Age 21 - 1 year of methamphetamines (weekly) amphetamines (weekly), hallucinogens (occasionally). 1 Year of using HGH, Steroids (Animal and Human), Clenbuterol, Duromine (all off and on). Now drug free.

Drugs: Take Zantac a few times a week and was on Aropax Paroxetine for depression and GAD at age 17. Took myself off them at age 20. No adverse symptoms noted.

Stress Levels at time of first incident: Medium-High

BP (sitting) 120/78
Pulse: 68
O2 Saturation: 99%
Apex beat: 5th intercostal space
Heart sounds: x2
No murmurs
Right Left
Right Left
Normal Normal
Normal air entry

In Sep 2013 I was under the affect of methamphetamine (brief 1-day relapse). Since this time I have not used any drugs. On the night, I began to feel faint. I could see everything begin to turn black. I nearly blacked out but managed to come to. I then begun having chest pains. I later went to the ER.

Test performed were ECG, chest x-ray, bloods (heart attack). All clear.

Follow up with GP. Requested resting ECG, TSH, HDL, UE, GLF, FBE, Urine, Stool O/B, Glucose, Helicobacter Serology.

Most tests clear. Slightly fatty liver and cholesterol levels slightly above borderline (HDL, tri, etc.)

Symptoms remained off and on in the coming months with stabbing chest pains, dizziness, palpitations, pain in left arm, etc. Pains are centre (sternum), just slightly to the left. Pains are also experienced just under left pectoral, also to left of pectoral, and in pectoral above nipple.

Saw another GP for a second opinion. He suggested a heart condition known as "Hocum". Hearing it could be my heart admittedly began a downward spiral of severe anxiety and magnification of symptoms. But I'm adament that the anxiety started -after- the symptoms occured.

The next 2 months saw me have 10 visits to ER with shortness of breath, pains down arm, dizziness, palpitations, chest pains, etc. ECG, chest x-ray, bloods all clear. Soon discharged.

I again visited my GP who ordered an Echo-doppler and Holter Monitor. These were the results :::

HOLTER MONITOR:

Sinus rythm with average heart rate 73 beats per minute.
Minimum HR 42bpm at 0832, maximum HR 139bpm at 1940.
Two isolated supraventricular ectopics.
One isolated ventricular ectopic.
One symptom of "palpitation" occured during sinus rythm with one vetricular ectopic. All remaining symptoms (chest pain, palpitations, dizzy spell) occurred during normal sinus rythm.


ECHO DOPPLER:

Technically difficult study.
Normal left ventricular size and systolic function. Left ventricular ejection fraction 56% by Simpson's biplane method. Normal left ventricular outflow tract without obstruction. Normal parameters of diastolic function.
Normal left atrial size.
Normal right heart chambers and valves. Normal TAPSE = 2.3cm noted.
Trileaflet aortic valve with good leaflet mobility.
Normal mitral valve structure and function.
Insufficient tricuspid regurgitation to estimate pulmonary pressure.
The inferior vena cava is not well seen.

Received another resting ECG, notes:
Sinus Bradycardia
Low Limb Lead Voltage

Received a further ECG, all appears normal.

Bloods again come back with somewhat fatty liver tissue.

I was finally tested with an abdominal ultra sound with the following results:

"The liver demonstrates a mild diffuse increase in reflectivity without marginal nodulation or secondary evidence of portal hypertension. Multiple mobile shadowing calculi are present in the gallbladder lumen measuring up to 15mm. The biliary tree is not dilated (3mm). No abnormality is seen in relation to pancreas of the paraaortic regions. Spleen and kidneys appear normal with no evidence of ascites. Mild fatty infiltration of the liver. Cholelithiasis. CT would better rule out urolithiasis if this is of ongoing clinical concern."

In the last 2 weeks my palpitations have been very strong, often waking me from sleep and making it hard to get back to sleep (can feel my heartbeat while laying down). They don't seem to occur as anxiety attacks, but rather just ongoing.

Pain radiating to back on the left side has been a common symptom. My carotid artery has been pumping very hard, particularly on my right side. I can also see my stomach (chest?) palpitate through my shirt, however the ultra sound technician says that my Aorta looked relatively normal with no distension.

Have also been getting burning sensation in pit of stomach, pains in various areas of abdomen including around belly button. Muscle spasms all over body. Neck pain (back of neck and right of neck). Spasms in pecs, also. Certain areas in pecs are painful when palpated with force.

Lots of acid reflux of late, headaches, pressure in head and ear aches. Hard to determine if related to anxiety. Do have eustachian tube blockage issues and often need ears syringed from wax buildup.

The gallstones don't seem to have been bothering me as I haven't really had any pain at the site.

Back pain is mostly upper back, mostly to the left.

Other possibly related info: Had inflamed lymph nodes for a few weeks in stomach area in 2010. Glands in neck have been hurting last couple of weeks. In 2012 I had pain in lower left portion of stomach and this pain has been ongoing. [?lymph node]. Have a couple of skin fungal infections, also have some cyst-looking objects above scrotum that disappear and re-form. There was a period between 18 years of age to 22 years of age where I was getting colds and flus violently, which caused violent coughing episodes.

Referred to cardiologist and for an endoscopy, but these will take months, so I am looking for some preliminary "hazard a guess" answers, and some interpretation of my results (good/bad?)

Should I be asking my doctor for different tests? What more can I do?

Is there anything my doctor or myself haven't considered?

And I guess I'm just looking for some reassurance. Am I dying?

Lymphoma? Abdominal Aortic Anuerysm? Brain Tumor? Carotid artery disease?

The main symptoms here are the left chest pains and palpitations.


Category: Cardiologist

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Category: Cardiologist
Dr. Vivek Mahajan is online now

Expert:  Dr. Vivek Mahajan replied 4 Days.

Hello
Thank you for your query at doctorspring.com.
You need to cut down your weight which should have been around 74 kg approximately.
I see that you have atypical chest pain palpitations and many other symptoms.
Given that your holter was normal at the time when you had similar symptoms indicates that the symptoms are not generated by a cardiac rhythm abnormality. Your echo looks normal. So a HOCUM or HOCM or hypertrophic cardiomyopathy doesn't seem to be an explanation.
Anxiety and depression seem to be a top possibility for these symptoms. One test that you could do is stress test to rule out a coronary artery disease as a cause of atypical chest pain. Though it is very unlikely to be a cause of your symptoms just to remove the doubt from your mind stress test may be advised.
All said and done anxiety seems to be the number one diagnosis and you should probably seek help from a psychiatrist to calm your fears.
You need not worry as your condition is nothing to worry and does not seem to be any of the serious conditions you have mentioned. Like I said anxiety and depression are likely to be the cause of your symptoms and you can easily be treated for it.
Please feel free to follow with any queries.
Regards
Dr Vivek Mahajan
DM Cardiology


Patient replied :

Thank you for your response.

Last couple of days I have had a Ripping or Tearing feeling in my Abdomen, in the middle and also near the belly button (in addition to other stomach pains). I can also feel the pain simultaneously in my genitals on occasion. My Abdomen has been pulsating. I went to my doctor today and he ordered an emergency ultrasound, in which it was difficult to see the aorta, but it appeared of normal size and only one tone of blood, not two-toned.

Would AAA or aortic dissection be a likelihood? Going back to doctor tomorrow but undoubtedly future tests will depends upon appointments.

Also I was offered a CT scan. I'm aware of the radiation risks so not sure if I should take it?

Trying not to stress but finding it hard.


Expert:  Dr. Vivek Mahajan replied 3 Days.

Hello,
It is highly unlikely that you are having AAA or aortic dissection as it would have shown on the ultrasound.
Secondly aortic dissection causes severe sudden low back pain, abdominal pain and groin pain. It is very severe in nature.
Patients have fainting episodes, may have nausea and vomiting.
Pulse drops, B.P drops and it cannot be missed on examination.
You need not worry as this is definitely not the cause of your pain.
C.T scan is not required, however you can get it done to completely clear your mind of this thought. One exposure will not put you at any danger.
As of now you need not worry. Like I said earlier I would advise you to get help from a psychiatrist to help you relax and not stress out.
I hope this has helped.
Thankyou


Patient replied :

One last question.. I'm going for a stress test on monday (treadmill ECG). Could the fact that I get exhausted after doing cardio (even a small amount) and my heart feels like it's going to jump out of my chest - could this simply be attributed to being generally unfit? Cardio has never been a strong point - I struggled even as a slender child. Also, could anxiety cause persistent palpitations? I don't get to see a cardiologist until May. Thank you for your help, I'm actively seeking psychiatrist help.


Expert:  Dr. Vivek Mahajan replied 2 Days.

Hello,

Poor exercise capacity is commonly due to deconditioning wherein you don't use your muscles and they and the heart are not used to exercise. That can cause fatigue and shortness of breath. Regular exercise can solve the problem.

Of course poor exercise capacity could also be due to cardiac problems but they are definitely the only reason for exercise fatigue.

A stress test not only documents the ecg changes during exercise but also documents how long you could exercise. Even if you don't have heart disease a low exercise capacity predicts a poor outcome in future.

So you should probably start exercising regularly and try to loose weight.
Anxiety can cause palpitations. Also poor exercise capacity can cause palpitations on exercising.

Regards
Dr Vivek Mahajan


Dr. Vivek Mahajan
Category: Cardiologist
Experience: 
Fellowship: DM, Cardiology, PGIMER, 2013
Residency: MD, Internal Medicine, AIIMS, 2007
Internship: King Edward Memorial (KEM) Hospital, 2003 
Medical School: MBBS, Seth G.S. Medical College, 2002
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