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CASES MATERIA MEDICA GENERAL ARTICLES ABSTRACT MISCELLANEOUS Q & A

Case 71: Case of Myocardial Ischemia.
Dr A R KAPSE

Mrs RAH. 52 yrs. Married since 25 yrs ago. EDUCATION: 4th Std. OCCUPATION: Farmer. RELIGION: Hindu, Varli community.

DIET: Mix (Veg/NV/egg).

FATHER: Died due to old age. MOTHER: Died due to old age. BROTHER: 3 (65yrs, 55yrs, and 42yrs). SISTERS: 63yrs

DATE OF CASE REGESTRATION: 12/9/2008.

TREATMENT

LOCATION SENSATION MODALITIES MODALITIES
CVS
HEART
Since 1 yr
On/off
1st episode on
7/6/07
SINCE 1 yr on/off
D=1hr-1day
Freq= 3-4 times /week
Pain3
Breathlessness +
BP: 200/100 mm of hg
Pain radiating to interscapular region
Retrosternal burning
No sweating
No palpitation
HOSPITALZED
Investigated (ECG, lipid profile, cardiac enzymes , BSL)
DIAGNOSED = ANGINA WITH HYPERTENSION
Mild chest pain2
Retrosternal burning +
Pain radiating to intrascapular region
No sweating
No palpitation
< Physical Exertion3
< Mental Tension2
< Hunger2
> Eating+
> Massage2
< Oily and Salty food3
Rx given on discharge
Tab Aten
Tab Sorbitrate
Tab Clopidogril
Tab Tg tore z
Tab Zee 0.5
Syr Smuth
IRREGULAR ON RX TOOK ONLY FOR 2MTS
< Overeating2
< Pulses3
> Drinking Water +
< 4-6 am3
< Fasting2
> Eating+
< Full Moon3
< New Moon3
Weakness+
Tingling on both soles+

PHYSICAL CHARACTERISTICS
APPEARANCE: Average build
SKIN: Cracks on soles in winter
PERSPIRATION: Moderate on face
THIRST: Ĺ Lit every 2 hrly
CRAVINGS: Fish+, spicy +
AVERSION: Sweets +
STOOL/ URINE: Normal
SEXUAL FUNCTION: Decrease freq due to disease anxiety.
SLEEP: Disturbed occasionally due to pain
DREAMS: Pursued of being - people are running after me and I reach home and mob goes away
MOTION SICKNESS: Bus < nausea

THERMAL STATE: CHILLY (C3H2) Covers head to foot, 2-3 coverings in winter

PAST HISTORY: Not significant

FAMILY HISTORY: Fa -Hemeplegia

PHYSICAL EXAMINATION: No oedema, cyanosis, clubbing, pallor.
Pulse: 88/min, T: 98.6F, BP: 160/90 mm of hg. P/A: Liver 2F tender. RS: / CVS / CNS: NAD.

INVESTIGATIONS
7/6/07: Hb: 13.5gms. WBC = 6400, N= 62, L=34, E=03, M=01, B=00. ESR=38. SR CREAT= 0.8, UREA= 20, CPK NAC= 309?, CPK MB= 10 (N). LDH = 107. Sr Na =140. Sr K= 3.4. Sr Cl =106.
12/09/08: ECG: ST changes in II, III and aVF leads. Diagnosis inferior wall ischaemia.

LIFE SPACE INVESTIGATION
52 yrs male came to OPD with c/o of chest pain and much anxiety, he said it was due to retrosternal burning, he was asked if any past h/o of chest pain or hypertension, he refused and after much inquiry he said, yes in past he had chest pain ie a yr back which was typical as per the previous reports with him. He was trying to hide his illness.

Pt is from small village where he lives with his wife and 3 children. He is farmer by occupation and owns 2-3 acres of land. Wife and children help him in farming .He was born in a joint family; had 2 uncles. All affairs of the family were looked by elder uncle. Fatherís nature was very quiet and cool. He never had fights with any one; he also never opposed anyone. Motherís nature was strict and dominating. Uncle was short tempered and alcoholic and dominated whole family. Ptís father had 2 wives. He had no children from 1st wife so he married 2nd time. 1st wife also stayed with him. Pt said he loved and was attached to the 1st mother than his real mother as she cared for them more than there mother.

He studied upto 4th Std. He was interested to study but his Fa told him to leave studies and pay attention to farming, so he had to leave it. It was against his wish but as father had told so he had to accept. Still he used to go to school hiding from his father, but later left it totally and joined farming. Other siblings were also doing same. He then got married. It was an arranged marriage. He thought of doing tailoring. He first learned it under a tailor and then started taking his own orders. He started his shop in nearby city almost 7-8 kms away from his home. He used to go walking then later by cycle. He worked hard to support the family; all income was given to father as he was head of the family. Afterwards everyone got separated and pt had 2 acres of land in his share. He then started farming again and also did tailoring. He worked very hard to bring up his family.

He arranged his daughterís marriage. Son in law was good by nature; many times he helped pt by giving money. Pt was almost dependent on him during stressful events. But, 2 yrs after the marriage his son in law died in an accident which was very shocking for pt. He felt as if there is no security left, he stayed at his daughters place for about a month after son in laws death. His granddaughter was kept by in laws, and he along with daughter came back as other sister in law said why should we keep her here now that her husband is dead? During that whole month, patient had to face daily up and downs. He had no support; he started consuming more alcohol and experienced chest pain and later developed so severe pain, was hospitalized and diagnosed to have hypertension and angina. Now on asking him what about his daughterís remarriage, he replied calmly, "It depends on her, if she wants, we will help her." But it was apparent that he felt more bad about loss of his support.

Now he is staying with his daughter, son and wife. He is not much interested in family matters. He says that everyone is good with me, take care so why should I have any complaints? I get my food at time why should I complain. Overall during interview he contradicted himself many times. He seemed to be a calm, dependent and anxious person. If work is not done on time he gets irritated and shouts on others.

  Chest Pain Intensity Chest Pain Freq Dyspnoea <Exertion Retrosternal Burning Dreams Blood Pressure  
12/09/08 12.45 ++   ++ ++   150/100 Cactus 200 stat
12/09/08 1.25 pm > 50%   > 75% A   136/96 Observe
12/09 11.30 pm > 75%   > 75% >3   160/100 Sil 200 1P HS
14/09 MILD   A A   160/100 Sil 200 1P Stat
19/9/08 > 75% 3 times Less >2+ Pursued by bulls 140/100 Sil 200 7P HS
26/9/08 > 75% >2 + 0 Climbed tree which fell in water but pt safe 138/92 Sil 200 7P HS
10/10/08 >3 >3 > Can walk 1 km > Temples, vehicles 130/80 Sil 200 14 PHS
24/10/08 > + A A   0 120/80 Sil 200 14 HS

Case: 72
Doctor I Feel Helpless and Unfortunate!

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