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Woman With Breathlessness: An Angina Variant

BREATHLESSNESS: AN ANGINA VARIANT

A 37 years female banker presented to us on 1/4/14 with complaints of breathlessness on slightest exertion, particularly on ascending stairs since 3 years, but increased since 13 days. She had a dry cough along with breathlessness whenever the patient walked fast. There was no history of chest pain, headache and vertigo. She was on Salbutamol inhaler with no relief.

Physical generals: Chilly, Appetite: Normal. No specific desires or aversion for food. Thirst: Normal, thirsty during attacks of breathlessness. Sweating / Urine/ Stool: Normal, Menses: Regular 3/30 days, average flow, mild dysmenorrhoea (no medication was required), No leucorrhoea. Sleep:Normal, Dreams not specific.

Mentally calm but whenever angered used to express out. She had persistent stress of her job. She preferred solitude especially when she used to experience such attacks of breathlessness. Can laugh or cry easily. She enjoyed music of all types.

PAST HISTORY: - No History of Systemic Hypertension, Diabetes, Rheumatic heart disease. She was taking allopathic medicine for breathlessness. She was treated as asthmatic but no investigations were at hand.

G2 P2 A0 L2- Elder son & younger daughter. Both pregnancies were uneventful and were full term normal deliveries. Both were breast fed for around a year.

FAMILY HISTORY: - Mother-Diabetes Mellitus + Hypothyroidism. Maternal aunt - Diabetes Mellitus with Hypothyroidism.

On Examination:-

·        Overweight- 78kgs,

·        Afebrile

·        Pulse-Regular,90/min, good volume, synchronous.

·        R/R:-22/min

·        BP:-136/90mm Hg

·        Pallor-Mild, No icterus/cyanosis/clubbing

·        JVP not raised

·        No oedema feet.

·        No lymphadenopathy

·        Skin/Spine/Joints-Normal

·        HS-Pure,No gallop

·        RS-Clear, No Ronchi/Rales

·        PerAbdomen-soft, Liver/Spleen Not palpable, Kidney non ballotable

·        CNS- NAD

MANAGEMENT:-

Patient was investigated

1.     Electrocardiogram-T wave inversion in II, III aVF during episode of breathlessness but resting electrocardiogram was normal.

2.     2D Echocardiogram – Normal chamber dimensions. No RWMA, Diastolic dysfunctionpresent. Ejection fraction 60%

3.     TMT-Strongly positive for Inducible Ischemia

The following rubrics were selected

1.     Respiration difficult ascending

2.     Respiration difficult exertion after

3.     Prefer solitude especially during the attack

Among the many, the following remedies were prominent – Natrum Mur, Coca, Calcarea carb

1/4/14: Natrum mur 0/1, 3 doses at 6 hourly interval for 1 day.

5/4: No special relief noted. Had dyspnoea while bathing. ECG – Within Normal Limits. Natrum Mur 0/2, 3 doses for 1 day.

16/4: No relief. Had 3 such attacks in a week. On the insistence of her family, visited a cardiologist: started on anti-anginals, aspirin and statins. She came to me for seeking permission to start allopathy. Having told her to withhold the allopathic prescription, we gave her Coca 0/1 BD for 3 days

23/4/14:No angina attack for this entire week. Exerted herself in a wedding but had no complaints.

DISCUSSION - LESSONS LEARNED:

1. This is a Case Type, meaning thereby, it is a Natural case with no suppressions.

2. Since she had presented to us in an acute event, it was imperative to first treat the acute state and settle her. Natrum Muraticum even in ascending potencies did not oblige. Coca did a wonderful job.

3. During the writing of this case she has been given her constitutional drug that is Calc Carbonicum to prevent such recurrences in future and if possible to bring the Treadmill Test negative for inducible ischemia.

This case had predominantly presented us with breathlessness without any chest discomfort orany autonomic nervous system disturbances during the episode of angina. She was mistakenly treated for 3 years as a case of bronchial asthma without any relief. It was only ECG and a 2D Echo-cardiogram during an attack that clinched the cardiac origin of this breathlessness. Such a type of presentation is an angina variant and is generally in Diabetics developing atherosclerotic changes in the coronary arteries and also in pre-diabetes.

LINKS

JAMA: Cocoa Intake, Blood Pressure, and Cardiovascular Mortality |  Small, short-term, intervention studies indicate that cocoa-containing foods improve endothelial function and reduce blood pressure. We studied whether habitual cocoa intake was cross-sectionally related to blood pressure and prospectively related with cardiovascular mortality.

NCBI: Chocolate and Prevention of Cardiovascular Disease: A Systematic Review |Consumption of chocolate has been often hypothesized to reduce the risk of cardiovascular disease (CVD) due to chocolate's high levels of stearic acid and antioxidant flavonoids. However, debate still lingers regarding the true long term beneficial cardiovascular effects of chocolate overall.

chocolate

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Comment by Dr.Venugopal Gouri on August 16, 2014 at 5:14am

Thank you Dr.Adil Chimthanwala for treating and explaining the case in a very simple way. This type of analysis wherein the patient is investigated for the possible causes of the problem and then looking to bail the patient of the acute episode while having a chronic remedy at hand to treat the cause will actually take Homoeopathy a long way.

I wish the younger practitioners adopt this pragmatic method.

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