Back and chest pain. ECHO, MRI,CT, ECG.

Resolved question:
Respected sir/madam,
I am ranjith, 29 year old male from India. I am suffering from upper Bach pain left side and left side chest pain since one year. I went to many doctors and underwent several tests like ECG , echo , tmt, MRI brain, MRI chest, ct chest and all blood tests. Every thing is normal.
I am getting leg pain and weakness and dizziness and giddiness.


Kindly suggest what I have to do.

Thanks and regards
Ranjith

Submitted: 4 Days
Category: Internal Medicine Specialist

Expert:  Dr. Jaydeep Tripathy replied 4 Days.

Hello.
Thank you for posting your query at DoctorSpring.com
I understand your concern.
It is a good thing that all your tests are normal. So something serious can be straight away ruled out.
Now i need some more information from you before i can arrive at a conclusion :
- Is the pain present through out the day?
- Does the pain radiate anywhere
- On a scale of 1-10 how will you rate the pain?
- What about your appetite?
- What is your height and weight?
- What is your current occupation? How long do you work per day? Is there any reason for stress?
- How is your sleep?
It seems to be more fatigue related, however with answer to these questions, i will be able to guide you better.
Awaiting your reply,
Regards.

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Patient replied :

Respected sir,
My appetite is normal. Pain is present through out the day.
Night time I will get up as I feel some breathing problem. Suddenly I will get up.
Pain radiates to left arm also . Some times right arm also (very less). Now my legs are also paining. Not able to walk for 10 mints. I feel very tired.
i will rate my pain as 7 both left chest and upper back.
i am working in insurance department. Administration side. Less stress. 6 to 7 hours I work.
Small baby in my house so night time sleep disturbance is there. ( one year baby)
75 weight and 5.11 height.

thanks and regards
ranjith


Expert:  Dr. Jaydeep Tripathy replied 3 Days.

Hello.
Thank you for the follow up.
In absence of any positive finding in th series of tests that you took, which ruled out all serious possibilities, there are couple of issues that could be causing your symptoms.
1) Chronic Fatigue Syndrome : This is an aytypical syndrome, where a person gets tired very easily, and no matter what the workload, is extremely fatigued through out the day. There will be a dull and vague through out the body which will be unrelated to any particular symptomatic disease.
2) GERD : The second possibility is gastro-esophageal reflux disease which can be asymptomatic barring slight chest pain, upper back pain, and at times breathing discomfort. Such persistent pain ultimately leads to the spread of pain in other areas.
In the view of above possibilities, i will advise you the following medicines. Please continue them for 2 weeks and let me know if you're getting better.
1) Cap Omeprazole 20 mg, once in the morning 30 minutes before breakfast for 2 weeks.
2) Syp. Gelusil MPS 2 teaspoons, three times daily after each meal for 2 weeks.
3) Tab. Ibuprofen 400 mg twice daily, 1-0-1 after food for 7 days.
All these are over the counter drugs. Please continue them and let me know if your symptoms are getting better.
Have you received any similar treatment before? If yes, please reply as a follow up.
Regards.

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Patient replied :

Respected sir,
I went to neuro surjery. he gave me DECORATE ER 250 mg. two times daily.
Sorry sir I forgot to say this.
ranjith


Expert:  Dr. Jaydeep Tripathy replied 2 Days.

Hello.
Thank you for additional information.
Please continue with what i told you.
Why were you given Dicorate? Because you have not given any other history. Did the doctor menion why he wanted you to take that medicine?
Regards.

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Patient replied :

Respected sir,
I got severe headache, I went to neuro surgeon. He conducted two tests EEG and MRI brain. In EEG the result came as. Left temporal focus.. MRI brain is normal.
so he advised me to take the decorate er 250 mg twice daily. For 30 days
with that he gave flexura d for pain. For 7 days.
now 10 days over I stoped flexura d.
head ache is normal. But other pains are still existing.
mainly leg weekness.

sir my lipid profile is as follows,
tryglicerides. 273
hdl. 26
ldl. 98


thanks & regards
Ranjith


Expert:  Dr. Jaydeep Tripathy replied 1 Day.

Hello.
Since this is your last follow up, i will put everything here whatever advise i wanted to give you.
I just wanted to ask you about your lipid profile and thankfully you yourself put it up.
Your TGL are very high and it is possible that you can go in for early atherosclerosis, which is a predisposing factor for MI/Stroke. Please discuss with your doctor and if medicine for high cholesterol is required, you can start it. Even your LDL/HDL ratio is impaired and the good cholesterol HDL is very low, which actually offers protection to your heart. If possible start brisk walking, around 3-4 kms per day within an hour. Try to exercise 4-5 times a week.
Regarding your headache, i will advise even if you have recovered please follow it up with your neurosurgeon after 1 month's time.
Follow the guidelines i gave you. Lose weight and try to get your cholesterol levels down to normal. Your LDL is not high and that is a good sign, but the other parameters have to be taken care off.
Also repeat an ECG after a month, and i will also advise a follow up with the cardiologist if your pain does not subside. Just as a precautionary measure. Even he can guide you, about the statins ( medication for cholesterol ).
Take care,
Wish you a speedy recovery,
Regards.

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