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O P Kapoor

Ex. Hon. Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.

In private practice, a lot of patients waste your time (and many deserving patients do not get your time) not because of the suffering but because of the anxiety about the cause and the diagnosis of their complaint.

Anterior chest pain specially on the left side is one of those symptoms. Most of these patients have no risk factors. They are young, are non-diabetic or non-hypertensive, are non-drunkards and non-smokers, have no family history of heart disease and are not obese and are often females. Thus it is very easy to exclude anginal pains specially because such patients often complain of pain at rest, on lying down, or while working in the house or kitchen or in the office.

Though there are numerous non-cardiac causes of such pains, some of them are very easy to exclude. Presence of cough and pleural pain will exclude Koch’s, pleurisy and pneumonia with the help of a single X-ray chest. Do not forget to palpate the male breast for early gynaecomastia which nowadays is most often iatrogenic and can cause pain.

Chondritis is easy to diagnose because of the local tenderness of one of the costal cartilages. The short duration of burning pain (patient not allowing you to touch the chest) will help to exclude early herpes zoster before the rash appears. Pectoral muscle pain with tenderness is common in patients who use two wheelers and are left handed.

Not an uncommon cause to explain such pains is cervical spondylosis at an unusual higher level with compression of C4,5 roots. Like inter-scapular pains, these patients can complain of anterior chest pain often at rest or while turning in bed or while working in the kitchen or at an office table.

The X-rays of the cervical spine often do not give a proper diagnosis or it can be an incidental finding. In such a situation it is always better to refer these patients to a neurology department of a big hospital and ask for a test called "Somato sensory evoke potential studies (SSEP)".

Somewhat like a test of electro myography and nerve conduction studies, this test can diagnose a "root" lesion due to compression and confirm the diagnosis of cervical spondylosis. Use of a cervical collar for a days, a small pillow, neck physiotherapy and passage of time help to get rid of these pains.

The most important point is that in private practice these patients go on changing their doctors and waste the time of their family physicians just because they are not convinced of the cause of their chest pains. Now that such tests are available in most of the neurology departments of all the leading five star hospitals, why not to take advantage of it, specially because it is not a very costly test (Rs.1500/-).

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