patient Number

9702873584

age

49

gender

Female

occupation

HOUSEWIFE

chief Complaint

Chief Complaint Pain radiating from neck to left shoulder and elbow to fingertips. Left shoulder joint pain. Pain marked on touch. Pain at the post-operative site. Burning pain over inner aspect of the arm/post-operative side. Sudden jerking pain in left arm/hand. Numbness and tingling from fingers to shoulder. Whole tongue becomes dry during severe pain. Pain < touch. Pain < lifting hand upward. Pain < movement. Pain < physiotherapy/exercise. Pain > slight/light pressure. PAIN AGGRAVED BY REST ; SLEEP AND IN NIGHT AND WHILE LYING DOWN

physical History

General Symptoms Appetite normal. Thirst increased; drinks only when in pain, otherwise normal. Tongue clean, moist. Profuse sweating. Sweat only on exertion. Stool normal. Sleep disturbed because she wakes to help husband. Sleeps mainly on left side. Sleeps due to pain. Dreams absent/not remembered. No significant thermal symptoms elicited. ast History Uterine fibroids (2022). Initially treated with hormonal medicine and homeopathy. Developed invasive carcinoma of left breast (HER2-positive, ER 5/8 positive, PR negative). Neoadjuvant chemotherapy (Paclitaxel + Trastuzumab followed by EC). Left Modified Radical Mastectomy with Axillary Lymph Node Dissection (May 2025). Post-operative histopathology: DCIS (pTis N0). Chest wall and nodal radiotherapy completed. Maintenance Trastuzumab completed. On Tamoxifen 20 mg. Historical treatment details documented Particular Symptoms Left shoulder pain extending to elbow and fingers. Burning pain. Tingling and numbness. Jerking sensation in left upper limb. Pain at operation scar. Pain in post-radiation area. Cannot lift left arm comfortably. Difficulty using left upper limb. Pain interferes with sleep. Pain after physiotherapy. Pain better by light pressure. Tongue dryness during painful episodes. Past History Uterine fibroids (2022). Initially treated with hormonal medicine and homeopathy. Developed invasive carcinoma of left breast (HER2-positive, ER 5/8 positive, PR negative). Neoadjuvant chemotherapy (Paclitaxel + Trastuzumab followed by EC). Left Modified Radical Mastectomy with Axillary Lymph Node Dissection (May 2025). Post-operative histopathology: DCIS (pTis N0). Chest wall and nodal radiotherapy completed. Maintenance Trastuzumab completed. On Tamoxifen 20 mg. Historical treatment details documented. Investigations MRI Cervical Spine Mild cervical spondylosis. C4–C5 and C5–C6 disc indenting the thecal sac and abutting the spinal cord. Posterior disc bulges at C3–C4 and C6–C7. Degenerative changes. MRI Left Shoulder Supraspinatus tendinosis. Mild subscapularis and infraspinatus tendinosis. Mild biceps tendinosis. Mild subacromial-subdeltoid and subcoracoid bursitis. Features suggestive of mild adhesive capsulitis. Mild acromioclavicular arthrosis without impingement

mental History

Mental Symptoms Thinks there is no future for her. Feels there is no cure. Believes husband's health will worsen because of her illness. More worried about her husband's health than her own. Feels guilty that her illness is causing burden to husband. Fear that husband may develop uterine cancer (delusional/fixed fear related to illness). Anxiety regarding daughter's future. Wants to go out somewhere when anxious. Hurries/rushes while going out. Feels stuck between husband and daughter. Reserved; does not express emotions easily. Blunted/flattened affect. Feels spiritually finished/empty. Feels life is over. History of emotional trauma after diagnosis and treatment.

duration

6 MONTHS

severity

better From

worse From

REST ; LYONG DOWN; NIGHT

desires

SWEETS

aversions

FATS

weight

62

height

152

diet Type

Vegetarian