What are the causes and management of chest pain?

Question

Hello doctor,

My mother is 55 years old. She takes Metformin with Vildagliptin for diabetes and Thyroxine for thyroid daily. Her diabetes is under control, with her HbA1C also within normal limits. We had tests done four months ago, and her fasting blood sugar was around 100 mg/dL. About 25 days ago, she experienced pain on the left side of her chest, which could be pinpointed to the last few ribs just above the stomach. The pain reappears when pressed at that specific point and worsens when she takes very deep breaths or sleeps on that side. We consulted a doctor, who advised a chest x-ray and ECG, both of which were normal. The doctor recommended applying DFO gel. During this period, she also experienced weakness and fatigue. After 15 days, although the pain had significantly decreased, she still felt slight discomfort while inhaling deeply and continued to feel weak. The doctor then suggested a CT scan of the chest and recommended calcium and vitamin supplements.

Now, there is no pain, even when pressing on the area or taking deep breaths. Occasionally, she experiences slight discomfort while sleeping on the same side, sometimes at the back or below the rib cage. I am also concerned because I noticed she has lost 4 pounds in the past month without any changes to her diet, and over 11 pounds in the past one and a half years. However, her energy levels are almost back to normal. She tends to feel the heat more than others, and her last blood pressure reading was 130/77 mmHg, with a heart rate of 97 bpm. She is also feeling more thirsty than usual.

My questions are:

Should I get the CT scan done? Is the benefit worth the radiation risk?
What should I do about her weight loss?
Is any further investigation warranted here?

Please advise.

Answer 1

Hello,

Welcome to icliniq.com.

You have neither mentioned the duration of diabetes, nor the latest fasting and postprandial (PP) blood sugar levels, HbA1c (glycated hemoglobin) value, or the latest TSH (thyroid-stimulating hormone) levels. Please provide this information, as well as her blood pressure (BP). Furthermore, the description of the chest pain suggests a few possibilities:

Simple muscle spasm between the ribs (which would have likely improved with a short course of muscle relaxants and would not have warranted further tests, including a CT scan).
Inflammation of the left lung lining (pleura), which, if associated with weight loss and low-grade fever, could indicate tuberculosis.
Coronary heart disease, especially considering the chest pain is associated with weakness and fatigue, which is common in individuals with long-standing diabetes.

I would, therefore, strongly recommend that she undergo either a treadmill stress test (TMT) or stress echocardiography to exclude or confirm heart disease. Regarding her weight loss, it is a common occurrence in diabetes. The anti-diabetic drug Metformin can lead to weight reduction. Additionally, successful correction of hypothyroidism may result in weight loss. For her age and height, she is still overweight by about 6 pounds.

I would recommend the following initial investigations:

An ultrasound of the left side of the chest to detect any fluid in the pleural cavity.
TMT or stress echocardiography to exclude or detect latent heart disease.
Lastly, I do not think a CT scan is necessary at this stage. If she continues to experience chest pain, a short course (five to seven days) of tablets of Diclofenac sodium and Paracetamol, one tablet three times daily after meals, should alleviate the pain, assuming it is due to muscle spasms in the chest.

Sending the requested reports would certainly help me reach a definite conclusion.