36/ F with Myalgia

 Patient came to the opd with chief complaints of left sided chest pain and sob since 1 year

HOPI:

Patient was apparently asymptomatic 1 year back then she developed left sided chest pain which is non radiating.

C/o sob grade II since 1 year .Which was insidious in onset and gradually progressive. Increases on lifting heavy weights( >/= 5 kg) and on supine position and  Associated with palpitations.

No H/o orthopnea, PND, weight gain

No C/O fever, vomitings , loose stools, burning micturition, cough.

Daily routine:

Patient used to wake up at 5 AM and drinks tea at 7 AM

And have breakfast at 8 AM (rice)

After having breakfast, she goes  to work at the construction site as a daily labour and eats her lunch at 1 PM (rice)

Then after eating rice, she gets back to her work 

She leaves the construction site at 5 PM. And goes back to home and have tea at 5:30 PM.

And have her dinner at 8 PM 

And goes back to sleep at 9 PM 

Patient started to feel shortness of breath one year back. Then decided to discontinue her work as a daily labour.

Her owner also suggested  not to continue as a daily labour

Then she started to work occasionally as farmer in her own cotton field along with help of some workers under her supervision

Past History:

 Not a k/c/o Htn, dm, thyroid disorders, asthma, epilepsy.

Personal History:

Diet: Mixed

Appetite: normal

Bowel and bladder: Regular

Sleep: adequate

Addictions: no

Patient was born in a family with both parents. More along with 4 sisters and 2 brothers 

at the age of 2 patient lost her father and her elder brother

During her schooling age, patient lost her mother & and her younger brother

She was married in the year of 2000 which was consanguineous marriage  and her sisters were against it

Then, after five years, she gave birth to a girl Child for which her husband left her and married another woman

Since then she is a single parent 

And  then she worked in a poultry farm for 3 years 

After that she started working in construction site has a daily labour and then has a farmer.

General examination:

Pallor- mild present

No icterus, clubbing, cyanosis , lymphadenopathy, edema

6 min walk test--

Before

Bp: 120/70 mm Hg

Pr: 96 BPM

Rr: 24 cpm

SpO2: 97

After:

Bp: 130/80

Pr: 94 BPM

Rr: 27

SpO2:97

Systemic examination:

CVS: 

Inspection: 

No dilated  scars, sinuses, engorged veins.

No precordial bulge

Chest wall is symmetrical 

Palpation:

No local rise of temperature

Mild tenderness present

Apex beat felt at 5th intercoastal space

Auscultation:

S1 S2 heard, no mumurs

CNS: NFD

P/a: soft

Rs: blae +

Chest is symmetrical

Trachea is central

No scars, sinuses, engorged veins

Movement is symmetrical on respiration 

Diagnosis:Myalgia

Treatment: Amitriptyline 10mg PO before dinner for 5 days