02/06/2026
🚨 NOT ALL CHEST PAINS ARE CARDIAC!
By
Dr iFTHi
🪨 The Stone Behind the Chest Pain - 📚 The Diagnosis Was in the History, Not the Holter
A Missed Gallbladder Case Hidden Behind "Heart Weakness"
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🔹 TOPIC
Atypical Presentation of Cholelithiasis Mimicking Cardiac Disease
🔹 SUBTOPIC
Role of Detailed History Taking in Identifying Non-Cardiac Causes of Chest Pain
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📋 CASE SHEET
👩 Age/Sex : 34-year-old Female
💍 Marital Status : Married
👶 Obstetric History : Mother of 3 children
⚖️ Build : Obese
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🩺 CHIEF COMPLAINTS
• Palpitations – 6 months
• Chest Tightness – 6 months
• Retrosternal Pain – 6 months
• Upper Back Pain – 6 months
• Unusual Weakness – 6 months
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📖 PAST CONSULTATIONS
➡️ Consulted multiple General Practitioners
➡️ Referred to Cardiologist
Investigations done:
✅ Routine Blood Tests
✅ ECG
Treatment given:
💊 Propranolol
💊 Pantoprazole 40 mg
❌ No significant relief
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📖 FURTHER CARDIAC WORKUP
✅ Echocardiography
No significant abnormality detected
Treatment modified:
💊 Propranolol continued
💊 Pantoprazole continued
💊 Nexito added
⚠️ Partial relief only
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📖 FOLLOW-UP
New complaint:
• Constipation
Further investigation:
✅ Holter Monitoring
No significant abnormality detected
Treatment:
💊 Cremaffin added
❌ Symptoms persisted
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🏥 PRESENTATION TO MY CLINIC
Patient presented requesting medicines for:
❤️ "Heart Weakness"
(as explained to her by previous treating physicians)
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🔍 DETAILED HISTORY REVEALED
⭐ Symptoms frequently aggravated after fatty/oily meals
⭐ Pain located in:
• Mid Sternum
• Epigastrium
⭐ Pain radiating to:
• Right Shoulder
• Right Subscapular Region
⚠️ These findings shifted suspicion away from a primary cardiac cause.
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📝 INVESTIGATION ADVISED
✅ USG – Whole Abdomen
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📄 USG REPORT
🪨 Cholelithiasis
• Multiple Small Gallstones
🫀 Liver:
• Grade II NAFLD
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🎯 FINAL CLINICAL IMPRESSION
Primary Diagnosis:
🪨 Cholelithiasis with Typical Biliary Pain Radiation
Associated Finding:
🫀 Grade II NAFLD
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✨ HIGHLIGHTS
🔸 Six months of symptoms treated as possible cardiac disease
🔸 ECG, Echo and Holter essentially non-contributory
🔸 Key clue was relation of symptoms to fatty food intake
🔸 Right shoulder and right subscapular radiation pointed towards biliary pathology
🔸 Diagnosis was suspected from history before imaging confirmation
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📚 TEACHING POINTS
✅ Chest pain ≠ Always cardiac pain
✅ Never ignore food-related symptom patterns
✅ Always ask about pain radiation
✅ Epigastric pain can masquerade as chest pain
✅ Detailed history taking remains the most valuable diagnostic tool
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💡 CLINICAL PEARL
"The diagnosis was not hidden in the ECG, Echo or Holter report.
The diagnosis was hidden in the history."
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🚨 MORAL OF THE CASE
Not all patients seeking treatment for "heart weakness" actually have heart disease.
A careful history can prevent months of missed diagnosis.
