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Suffering from chest pain. Medical test showed normal. Is this related to hormone release?

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Practicing since : 2009
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I have been to the ER twice now with chest pain, SOB, left arm pain, feeling of impending doom, left face warmth and carotid neck pain. OTher presenting symptoms are severe changes in blood pressure when I STAND, and rapid pulse as high as 144 and BP as high as 178/118 (sometimes diastolic 132). I feel exhausted. Pulse was over 140 this entire day til 6pm. I spent two days in a larger, more resourced hospital to no avail. NO ANSWERS were given. EKG normal, labs normal, Potassium only low value at 3.2 but is now at 3.8. Also troponin normal, US kidneys normal, Head CT normal, Electrophysiology table (TOPS) negative, and I still am having all the symptoms and literally cannot hold my head up I'm so sick. I need help and answers. Everything Cardiac seems normal. WHat else can this be? I'm wearing a heart monitor for a month and everytime I call in my data they say, "Its sinus rhythm in the 140's" I'm beginning to think this is related to hormone release or something else. Tests sent away that I am waiting on to rule out PHenocromocytoma
Please note that my BP has been elevated, not low. Orthostatic Hypertention, not hypotention. Initially this happened only a few times a day (about two weeks ago) now my pulse and bp remain elevated 24 hours a day with no relief. SHould they start looking at different things other than the heart? Is this Kidney, Female Organ, Serotonin SYndrome, Catecholymine?? THey just keep sending me home telling me I'm fine, yet I feel like I"m dying! THe only time I see a decline in my BP is if I lay down for an extended period of time. Example: BP after lying 136/100 as apposed to 156/124 which it was tonight
Posted Sun, 21 Oct 2012 in Hypertension and Heart Disease
Answered by Dr. Arnab Maji 6 hours later

Thanks for your query.

From your history it seems to me underlying cardiac disorders though you said your physicians have excluded cardiac diseases but no echocardiography is done yet to exclude valvular heart diseases. With your history there are possibilities of some valvular diseases like mitral valve prolapsed syndrome (MVPS), left atrial myxoma, aortic regurgitation (AR) and co-arctation of aorta (COA). These disorders need to be excluded by proper echocardiographic evaluation. Trans-esophageal echocardiography (TEE) may be done to exclude COA.

Among the extra-cardiac disorders the symptomatology of pheochromocytoma, thyrotoxicosis are consistent with your symptomatology. You have already sent the required investigations for pheochromocytoma. Please do some workup to exclude thyrotoxicosis like free thyroxin (FT4) and thyroid stimulating hormone issues (TSH). Discuss these issues with your doctor and do the necessary workup to exclude them.

If all the above mentioned tests are normal then probably you are suffering from panic disorder or generalised anxiety disorder. In that case you need to consult your psychiatrist.

Hope I have answered your query. If you want to know more you can write back to me.

Kindly write a review on my answer.

Wish you quick recovery.

Best Regards,
Dr Arnab Maji

Above answer was peer-reviewed by
Follow-up: Suffering from chest pain. Medical test showed normal. Is this related to hormone release? 2 hours later
Thank you for your rapid response. I guess that is one thing I should of added, that an ECHO was done which was perfectly normal. Secondly, I was told that all "Thyroid" labs were WNL, though I specifically couldn't tell you if that was the TSH, or FT4 (though I will find out).
Should this be related to anxiety, I've had severe anxiety provoking issues in the past and this has never been an issue. Recently in therapy, we are discussing some childhood events that were traumatic, though I have discussed them at great length in the past with no episodes like this. I guess more than anything, I'm someone who is healthy, normal BMI, I do crossfit workouts, I love the Lord,,, and yet I can't seem to figure out why I'm so sick.
If I check with Dr and all pheno specific labs are normal, and Thyroid levels are normal, is there anything else that could potentially be causing this terrible rapid pulse, and HTN ( and all the fun things that go with that)?
Thank you for your time! XXXXXXX
Answered by Dr. Arnab Maji 2 hours later

Thanks for writing back.

As echocardiography is within normal limit, cardiac diseases attributing to your symptoms are excluded. I think as your all thyroid labs are within normal limit hyperthyroidism is excluded already by your physician. In this situation there are two extra-cardiac diseases which can attribute to your symptoms. They are pheochromocytoma and hyperparathyroidism. You already said that workup for pheochromocytoma has already been done though report is pending. For hyperparathyroidism I will suggest you to go for serum parathyroid hormonal (PTH) assay along with serum calcium.

If all the above reports are within normal limit then virtually organic disorders responsible for your symptoms will be excluded. Then we have to think about functional disorders specially generalised anxiety disorders and panic attacks because they can cause same symptoms you are suffering from.

So this will be the approach to diagnose your symptoms. Thereafter you should wait for the pheochromocytoma reports and serum PTH and serum calcium reports. If they are found to be normal you should consult your psychiatrist then.

Hope I have answered your queries. If you want to know further you will write back to me. I am always here to guide you properly.

Kindly write a review on my answer.

Best Regards,
Dr Arnab Maji
Above answer was peer-reviewed by
Follow-up: Suffering from chest pain. Medical test showed normal. Is this related to hormone release? 9 hours later
Thats helpful, I have follow up with Dr on THursday.
I will leave this open till after that....then write a review
Answered by Dr. Arnab Maji 14 hours later

Thanks a lot for response.

Wish you coming up with a diagnosis and proper treatment.

Dr Arnab Maji
Above answer was peer-reviewed by
Follow-up: Suffering from chest pain. Medical test showed normal. Is this related to hormone release? 12 days later
Still struggling with hypertention, and elevated pulse (although that is not all the time now). Lately the fatigue is tremendous and I have a thumping behind my sternum. I also have pain in my neck and chest tightness.
My 24 hour urine only had one elevation but was not significantly elevated. My cortisol level came back low, and my c-peptide high. My blood sugar has been running excessively low. Still awaiting testing such as specialty labs on metanephrines etc. Those still have not came.
I just feel horrible. My chest pain has diminished, and my bp is still high but not as high. I simply don't know what is wrong. I can't see endocrinologist for 3 months. By then I think I will be dead!
Everytime I eat I get sick and have diarrhea. I just can't keep living like this. Any ideas?
Celiac disease? Could this just be a stress response causing low cortisol? and not a tumor? Why would c-peptide be high? my Bs is never high. Always low. Still concerned. Thanks. XXXXXXX
Answered by Dr. Arnab Maji 8 hours later

Thanks for writing back.

Your persistent low sugar level and elevated c-peptide level are suggestive of insulinoma which is an endogenous insulin secreting tumor.

To confirm the diagnosis of insulinoma you should have the following tests -
1. After 72 hour fasting with glucose only measure serum insulin and glucose level. If insulin:glucose ration is >0.3 then diagnosis of insulinoma will be established,
2. Repeat C-peptide level durin the same test and if it is found to be really high then insulinoma is suggested,
3. insulin level >6 U/mL when blood glucose is <40 mg/dL is indicative of insulinoma,
4. plasma -hydroxybutyrate level is also decreased in insulinoma.

You should go for these tests immediately without any delay to diagnose insulinoma. Your symptoms are also consistent with insulinoma.

If insulinoma is diagnosed with the above mentioned tests then the next step will be to localise the tumor. Endoscopic ultrasound (EUS) can efficiently localise the tumor. After localisation the tumor should be excised but before surgery it is very essential to control hypoglycemia. The hypoglycemia can be controlled by frequent small meals and the use of diazoxide (150–800 mg/day). This should be the ideal approach to the tumor. By all these i think you will be releived of your symptoms surely.

Therefore you consult another endocrinologist and go for the tests and required treatment.

I am waiting to listen you further.

God bless you.

Best Regards,
Dr Arnab Maji
Above answer was peer-reviewed by
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