A 37 yr old woman who came to OPD post MI

A 37 year old female came to OPD post attack of  MI 

Note - This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centred online learning portfolio and your valuable inputs on the comment box is welcome. 

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

23 August 2022

Manvi Sharma

2k18(roll no 88)

DOA of pt - 11 August 2022

Case - 

Pt. is a 37 yr old female. 

At the age of 15, she had typhoid. After that no major incident in her life except few occasions of fever, cough, and cold

From 2013 to 2015, she worked as a weaver. Once while returning home from work in the evening she claimed to have seen someone sitting below the trees in the dark. She got very scared and had a light fever, which was resolved with medication. 6-7 days later, she complained of uneasiness and while she was combing her hair, her husband noticed facial drooping, more noticeable when she smiled. She could not walk. Suspecting it to be a stroke, he immediately took her to a local quark, who gave her one injection. On returning home, she couldn't even stand, her hands felt numb and weak and her condition deteriorated. The next day she was taken to a Dr. who recommended she get admitted to a hospital. After staying in hospital for 6-7 days, she became alright. While her stay in the hospital HTN was also detected. She was shown some physiotherapy techniques and prescribed medications, following which she was alright for the next 6 months.

6 months later, there was an occasion in her house. She ate the previous day's cooked meals in the morning. After eating she started c/o left side chest squeezing pain, sweating, SOB and lightheadedness. The pain lasted from 9 am to 3pm. She was taken to Dr. who did an ECG and detected a heart attack. Recommended hospital admission. Stayed in hospital for 6 days. Using the prescribed medications her symptoms reduced. Chest pain would occur 1-2 times in 2-3 months and would last for 1-2 mins. 

In 2020, one day around 7am while sitting in a chair she started c/o seeing flashes of light revolving in the dark. Her body became stiff and felt confused, slurred speech, her legs, and hands felt weak and numb and started drooling. She was rushed to the hospital. I day later, started bleeding from the nose and mouth. Dr reported she again had a brain stroke. Her symptoms recovered but she still c/o blurred vision, so was referred to another hospital, which reported her eyes are fine. Vision later returned to normal. Returned home and till July 2022 everything was normal with medications. During her stay in the hospital, DM was also detected. On medication for the same.

On 7 July 2022, pt.'s husband's father died. She was a bit stressed because of that. On July 28, at 12am the night, she started c/o chest pain, which was not reducing even on taking medications. She started sweating profusely. The pain lasted the whole day. The next day she was taken to a Dr. who diagnosed it to be a heart attack and advised her to be hospitalized. Stayed in ICU for 5 days. The hospital advised her husband to take her somewhere else. Brought pt. to Hyderabad.

CURRENT CHIEF PROBLEMS AND PATIENT'S REQ.: Pt. c/o chest pain and had 3 incidents of CVA.

FAMILY HISTORY:

Father: was a TB pt.

Mother: had a stroke. Died after a few days

Elder brother: died due to a stroke

Elder sister: became paralyzed after stroke and died a few days later.

Younger sister: had a stroke causing facial palsy. Cannot walk or talk. Rt. had also paralyzed.

Previous reports - 

Provisional diagnosis-  CAD, CVA, DM