It's a Heartache !

P/P: Fulanah binti Fulan, a 22 years old female student, was admitted to Hospital Bahagia on 14 March 2010 at 6.45 pm through Emergency Department.

C/C: Heartache 3 days PTA

HPI:
Patient was doing great and excellent until 3 days PTA when she started to have a heartache. The heartache started suddenly at rest. It was intermittent with variable duration. The site of heartache is retrosternal and there is no radiation to any other site. She described the pain as having someone squashing her heart hard. It was a very severe pain that she gave 9.9/10 for the severity of the heartache. The heartache usually starts when she was alone. So, nobody seems to know what really happen. The aggravating factor is not known while the relieving factors are Solah and reciting Quran. The heartache is associated with a severe palpitation, tremors, dizziness and blurred vision.

SR:
General:
. Increase appetite
. No weight loss
. Fatigue

Respiratory:
. Not significant

Cardiovascular:
. Not significant except for those stated in HPI

Gastrointestinal:
. Diarrhea same day PTA

Urinary-genital:
. Frequency same day PTA

Central nervous:
. Not significant except for those stated in HPI

Musculoskeletal:
. Not significant

PMH:
. Of course it's not a first attack (she has had many heartache before)
. First admission
. No history of contact with sick people (but she doesn't really sure if the people she was in contact with have any pain inside them)
. She is allergic to sad songs and sad movies
. No history of blood transfusion
. No history of surgery

Drug Hx:
. Alpella (recurrent; drug abuse)
. Hamoodah Halib (reason unknown)

Family Hx:
. She lives far away from her family so she doesn't really know if there are any similar symptoms in her family. It's already midnight in her hometown and she's sure that her family is sleeping soundly right now. She will ask them tomorrow
. No family hx of DM
. Positive family hx of HT and goiter
. No family hx of any other chronic illnesses

Social Hx:
. Never smokes
. Insured by MARA
. No pet yet
. Great house


P/E: Cannot be done as the patient is not cooperative

Investigation:
There is no appropriate investigation for this patient. She has to investigate by herself, using her own brain and mind.

DDx:
1. Hyperaloneism
2. Preimtihanism
3. Idiopathic Heartache

Treatment:
Although the etiology is still unknown, the doctor decided to put her on some medication first:
1. Supportive
2. H2O
3. Happy songs (any class)

She is advised to avoid sad songs and movies, increase exercise and think positively. She is also strongly encouraged to do more of the relieving factors mentioned.


Prepared by,
Doctor Fruity binti Loops,
No Title (yet),
JUST, Jordan.



FootNotes:
P/P-Patient Profile
C/C-Chief Complaint
PTA-Prior To Admission
HPI-History of Presenting Illness
SR-Systemic Review
PMH-Past Medical History
Hx-History
DM-Diabetes Melitus
HT-Hypertension
P/E-Physical Examination
DDx-Differential diagnosis

p/s: it's a heartache, nothing but a heartache! XD