[15-03-2025 22:18] PPM 1: @~PPM3 please share in a timelined sequence the documented events in
this patient.
Also if possible take her history using the following points 👇
Please describe your patient's sequence of events that led to the current problems. Please begin the
sequence of events from the time your patient had absolutely no problems at all.
Please describe your patient's hourly routine over 24 hours when he was perfectly alright
Next please describe what happened to his hourly 24 hour routine once the disease took hold on his life
Please mention specifically which part of the patient's hourly routine was disrupted
What are the patient's current requirements from us like if we had to give him a single medicine which
problem would they prefer it to address?
Please post the patient's clinical photo of abdomen and arm muscle as demonstrated below in the image
here:
https://userdrivenhealthcare.blogspot.com/2024/08/template-for-pajr-user-driven-history.html?m=1
[16-03-2025 19:53] PPM 3: CHIEF COMPLAINTS -
1. Hypertension since 6 years
2. Snoring since 3 years
3. Left shoulder pain and burning since 7-8 months
HISTORY OF PRESENTING ILLNESS -
The patient was apparently asymptomatic 6 years back and then noticed profuse sweating, a sensation
of burning in the hand and feet. For this she went to the doctor and got diagnosed with Hypertension
for which she was prescribed TELMESARTAN 40mg OD after breakfast and METAPROLOL
SUCCINATE 25mg OD after dinner.
3 years back she started snoring in the night. she would start sweating and feel out of breath which
wakes her up atleast once during the night. For this she went to a nearby doctor and was told that she
had a deviated nasal septum for which she didn't get operated.
7-8 months back she started having discomfort, pain and burning sensation in her left shoulder, left ear
pinna and behind left neck which was insidious in onset. Because of this the patient is unable to rotate
her hand to her full extent and is unable to sleep on her left side.
PAST HISTORY
Patient has a history of swelling in her left shoulder 7 years back, (? lipoma) gradually progressive
which reduced on its own 7 months back.
K/C/O HTN since 6 years
was a K/C/O Hypothyroidism 10 years back and took Thyroxine 50 forgot to take one day and stopped
since then.
The patient has a history of slipping and falling on the ground 20 years back, and a history of falling
from the scooter 15 years back which caused her lower back pain which got better over time.
No history of Tuberculosis, Asthma, Epilepsy, CVA, CVD
Surgery History -
operated on right breast 30 years back for adenoma
LSCS delivery - 2006
FAMILY HISTORY -
Father was K/C/O DM type 2, passed away 18 years ago (age -72) due to stroke (had multiple strokes
prior)
Mother is a K/C/O Hypertension
PERSONAL HISTORY -
Patient is a nurse by occupation since 30 years (1994)
Patient belong to the upper middle class family and got married at the age of 29.
Her son got diagnosed with brain tumor at the age of 3YEARS, surgery was not indicative as the age
was a contraindicatory in his case so medications were continued and a minor supportive surgery was
performed. At the age of 7YEARS her son was attacked by left facial paralysis after which he was
again admitted and in the year 2008 he was operated and the tumor was removed.
in the year 2021 the patients son complained of severe headache and when on the way to the hospital he
felt unconscious in the ambulance. Upon examination he was diagnosed with the reoccurrence of the
brain tumor and internal bleeding for which he was operated. after the operation took place whole of
his left side got paralyzed which was treated with supportive PHYSIOTHERAPY. Now the patient's
son is able to move his limbs on the left side but still left with few restrictions in his fingers and wrist.
This scenario of her son's medical issue left the patient both FINANCIALLY and MENTALLY
INVESTED. And with time it took a greater toll on his finances and emotional mental status.
Diet - Mixed
Appetite - Normal
Sleep - No problem in falling asleep but gets up during the night due to feeling of breathlessness and
sweating.
Bowel - Regular
Bladder - Regular
Addiction -
No specific addictions
DAILY ROUTINE -
Wakes up at 6:30
Wakes up son
Does house chores
Has fruits for breakfast
Goes to her workplace by around 10:30am
Comes back at around 3pm
Has lunch with son
Evening goes to drop son for tution
Walks around 2km
Eats dinner at 10:30 pm
Feeds son at 11:30 pm
Sleeps at around 1am
[15-03-2025 19.55] PPM 3: 2nd June 2018
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