07-07-2024
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
Our patient is a 28yr old male who is suffering from abdominal pain and could not eat anything since 15days. Solid food is causing pain and also had jaundice and feels uncomfortable with direct sunlight.
His stool was so hard that he had blood tinged stools. He wa becoming weak day by day and had no interest or taste of food.
From his case history we found that 5 yrs ago he had difficulty in breathing and was administered oxygen in the hospital and was almost normal.
After this he had the problem of headache which continued till now alongwith his abdominal pain.
The patient has the addiction of Khoini (dry tobacco leaves) and also the habit of betel leaves and nuts.
The PHR Patient journey record PaJR transcripts below reflect the therapeutic uncertainities around the patient and their resolution through team based learning.
রোগীর বয়স ২৮ বছর।
পুরুষ।
পেটের সমস্যা, ১০-১৫ দিন ধরে কিছু খেতে পারছে না, শক্ত কিছু খেলে ব্যথা শুরু হয়, জন্ডিস আছে, রোদে গেলেই অস্বস্তি হয় চোখে অন্ধকার দেখে । পায়খানা প্রচন্ড শক্ত হয়ে গেছে ফলের পায়খানা করতে রক্ত আসে দিনে দিনে দুর্বল হয়ে যাচ্ছে যাচ্ছে খাবার রুচি নাই।
রোগী ইতিহাস পাওয়া যাচ্ছে তাতে দেখা যাচ্ছে পাঁচ বছর আগে ওর শ্বশুর বাড়িতে হঠাৎ প্রচন্ড শ্বাসকষ্ট শুরু হয় তারপর অক্সিজেন দেওয়ার পর হসপিটালে মোটামুটি সুস্থ হয়। তার কিছুদিন বাদে থেকেই মাঝে মাঝে মাথা ব্যথা শুরু হয় যেটা এখনো চলছে। এরপরই দেখা দেয় পেটের সমস্যা।
নেশা বলতে সামান্য খৈনি মাঝে মাঝে পান-শুপুরি খাওয়ার অভ্যাস আছে।
01/07/2024, 09:22 - Meta AI: Thank you for sharing this information. It appears to be a medical history of a 28-year-old male patient in Bengali. I'll try to summarize the key points:
- The patient has been experiencing abdominal problems for 10-15 days, with difficulty eating and pain after consuming solid food.
- He has jaundice, and his stool is very hard, leading to rectal bleeding.
- He has a history of sudden severe respiratory distress five years ago, which improved with oxygen therapy.
- He has been experiencing intermittent headaches since then, which are still ongoing.
- He occasionally consumes small amounts of tobacco and pan-shupuri (a type of betel leaf).
[01/07/2024, 09:38] PPM 1: Report shob normal dekhchi
Pet byathar bistarito history tar jonye kichu proshno rakhchi
All the reports seem to be normal, to know more about his abdominal pain want to raise some questions
[01/07/2024, 09:38] Patient Advocate27M Abdominal Migraine: কালকে ট্রেন থেকে নামার পর পাকা আম খেয়েছে তাতেও পেটে পছন্দ বেটা হচ্ছে।
ভাত তো খেতেই পারছে না।এ
এক সপ্তাহ ধরে শুধূ জল খেয়ে আছে।
Yesterday night, after Getting off the train he ate ripe mango, for this he is having too much pain.
Can not eat rice, from one week he is drinking water only.
[01/07/2024, 10:50] Patient Advocate 27M Abdominal Migraine: এখন কি খাবে একটু বললে ভালো হত।
Now what will he eat please suggest
[01/07/2024, 10:52] Patient Advocate 27M Abdominal Migraine: এখন বিছানা থেকে ঠিকমত উঠতে পারছে না একা।
He cannot get out of the bed by himself normally
[01/07/2024, 10:53] Patient Advocate 27M Abdominal Migraine: এইখান থেকে হাসপাতাল যেতে সময় লাগবে তিন ঘন্টা তো কখন যাবে উনি ক টার সময় , একটু বললে ভালো হতো স্যার
From his location it will take 3 hours to reach hospital, so when will he go?
[01/07/2024, 10:54] Patient Advocate 27M Abdominal Migraine: কালকেই যেতে চাইছে আরর ভালো লাগতেছে না ।
নিজের কষ্ট হচ্ছে হচ্ছে বাড়ির লোগো টেনশন করতেছে সবাই
He wants to go tomorrow, not feeling well, the family members are worried
[01/07/2024, 10:55] PAJR PHR MODERATOR: Adhikangsho report dekhchi March a unar matha byathar jonye korano Bortoman somosya holo unar pet byatha
All the reports are for his headache problem, now the main problem is his stomachache
[01/07/2024, 10:57] Patient Advocate 27M Abdominal Migraine: হ্যাঁ ঠিক তাই আর কিছু খেতে পারছে না আর পায়খানা করলে পায়খানার সঙ্গে ব্লাড আসে
Yes, and cannot eat anything, and blood comes with his stool
[01/07/2024, 10:59] Patient Advocate 27M Abdominal Migraine: আর aএকটা কথা রুদ্রে বেরোতে paren না প্রচন্ড রোদ উঠলে মাথা গরম ঘুরে আর ঝিমঝিম করে চোখের মধ্যে কিরকম জোনাকি পোকার মতো dekhe একটা চশমা nieche চেঞ্জার চশমাটা দিয়ে বের হলে আবার ঠিক আছে চশমা ছাড়া বেরোতেই parena।
One more thing, he cannot stay under the sun, under the scorching sun he feels like fainting, he feels like some fireflies are moving. He has a changer lense, without this lense he cannot go outside in the sun
[01/07/2024, 11:07] PAJR PHR MODERATOR: আপনার রোগীর সমস্যা সম্পর্কে আপনি যা শেয়ার করেছেন তা পড়ার পরে আমরা যা বুঝতে পারি, তিনি 2024 সালের মার্চের আগে একই ধরণের সমস্যায় ভুগছেন বলে মনে হচ্ছে?
From what we understand after reading what you shared about your patient's problem, he seems to be suffering from the same problem before March 2024?
আপনি কি দয়া করে শেয়ার করতে পারেন যে কোন তারিখে আপনার রোগী একেবারে ঠিক ছিল যখন তার অন্য কোন সমস্যা ছিল না?
Can you please share on which date your patient was absolutely fine when he had not any other problem?
01/07/2024, 11:08 - Patient Advocate 27M Abdominal Migraine: না
No
[01/07/2024, 11:22] PAJR PHR MODERATOR: @PAJR MEMBER 1 Would you have the time to make a WhatsApp call to this patient's advocate @PAJR MEMBER 2 @PAJR MEMBER 1and share more insights into his headache and abdominal symptoms since March 2024?
There's an interesting condition called abdominal epilepsy that he may fit into
[01/07/2024, 11:45] Patient Advocate 27M Abdominal Migraine added PA2
[01/07/2024, 12:03] Patient Advocate 27M Abdominal Migraine: পাঁচ বছর আগে মাথা ঘোরা হয়েছিল তারপরে শ্বাসকষ্ট হয়েছিল হওয়ার পরে কিছুদিন পর থেকে মাথাব্যথা শুরু করে মাথা ব্যথার পর এই মলয় চক্রবর্তী স্যার এর কাছে গিয়েছিলাম যাওয়ার পরে ডাক্তারবাবু রিপোর্ট করে বলেছিল যে onar মাথায় নাকি ব্লাড জমেছে তারপরে সে ওষুধ খাওয়ার পরে কিছুদিন পর থেকে দিন দিন খাওয়ার রুচি কমে যাচ্ছে আর খাইতে parche না ঠিকমতো মোটামুটি কুড়ি পঁচিশ দিন আগে থেকে একদম কিছু খাইতে parche না এখন তো শুধু জল ছাড়া কিছুই খাইতে parche না আর আমি আগামীকাল সকাল বেলা যাবো এখান থেকে।
5 years ago he had dizziness and had shortness of breath, after that started headache. Then he went to the local Doctor sir, and the doctor said Blood clotted in the head, after taking medicine his food taste has gone and had no interest in food, cannot eat anything. From 20- 25 days he is not eating and taking only water. He will go to the hospital tomorrow morning
[01/07/2024, 12:25] PAJR PHR MODERATOR: Kone oshudh khawar por ruchi kome jacche?
Otar chobi share korun
From which medicine he has lost food taste and interest in food please share the picture
[01/07/2024, 14:46] Patient Advocate 27M Abdominal Migraine: সেটা তো ঠিক বুঝতে PARCHE NA, কিন্তু দিন দিন খাবার রুচি কমে যাচ্ছে
He didn't know properly, but the food taste has gone day by day.
[01/07/2024 16.20] PA 27M Abdominal Migraine: কাল সকাল বেলা আপনার হাসপাতালে আসছে
He is coming to your hospital tomorrow morning
[01/07/2024, 16:27] PAJR PHR MODERATOR: Thik ache
Ok
[01/07/2024, 16:27] PAJR PHR MODERATOR: Eta bondho kore dewa jete pare
This medication may be discontinued
[01/07/2024, 16:28] PAJR PHR MODERATOR: Etao bondho kore din
This one also can be discontinued
[01/07/2024, 16:28] PAJR PHR MODERATOR: Etao ordhek kore khaan
This one may be taken half
[01/07/2024, 16:29] PAJR PHR MODERATOR: Je oshudh gunor chobi pathalen eguno apnar patient kabe theke khacchen?
From when he is taking these above mentioned medicines?
[01/07/2024, 16:38] Patient Advocate 27M Abdominal Migraine: গত চার মাস ধরে KHACCHE
From 4 months
[01/07/2024, 16:41] PAJR PHR MODERATOR: Char maash aage ki ki koshter jonye apnar patient tokhon daktar dekhiyechilen?
4 years ago for which reason your patient has gone to the doctor?
[01/07/2024, 16:44] Patient Advocate 27M Abdominal Migraine: শুধু মাথা ব্যাথা করত আর ওই রোদ্রে গেলে একটু মাথা ঘোরা ঘোরা ভাব হতো মাথা যখন ব্যাথা করত তখন স্থির থাকতে parto না মাথায় জোরে জোরে আঘাত করলে ভালো লাগে। লাগালে মানে বাড়ি দিলে ঠিক আছে তাহলে না হলে স্থির থাকতে parena
Then he had only severe headache, could not stay longer under the sun, had dizziness under the sun, only used to get relief by hitting on the head with hand, otherwise he couldn't stay calm
[01/07/2024, 16:52] PAJR PHR MODERATOR: Maatha byatha ta ko bochor dhore shuru hoyeche?
From how many days the headache has started
Koto din aage apnar patient sompoorno shushtho chilen?
How many days ago your patient was alright
[01/07/2024, 16:52] Patient Advocate 27M Abdominal Migraine: এই দু বছর আগে মাথা ব্যাথা শুরু হয়েছে তার তিন বছর আগে শ্বাসকষ্ট হয়েছিল
From 2 years the headache has started, and before that 3 years ago the shortness of breath happened
[01/07/2024, 18:12] Patient Advocate 27M Abdominal Migraine:হায়দ্রাবাদের পাঠান চুরু এলাকায় ache ।এখান থেকে শর্ট কোন রাস্তা থাকলে বললে ভাল হয়। এখানকার তো কিছু chene না। থাকলে লোকেশন একটু পাঠিয়ে দিলে ভালো হতো স্যার।
He is now at Patancheru locality. From here please suggest any shorter road. He doesn't know anything. Please share the location.
[01/07/2024, 18:59] PAJR PHR MODERATOR: @pajrmember 3 This long distance patient's advocate @pajrmember4 needs to reach our hospital and is currently in Patancheru. Can you guide him how to reach here?
@pajrmember5 Can you share the location of our hospital from your phone here
[01/07/2024, 19:02] Pushed Communicator 1N22: Kamineni Institute of Medical Sciences
[02/07/2024, 08:54] Patient Advocate 27M Abdominal Migraine: স্যার আমি হাসপাতালে যাওয়ার জন্য বের হয়েছি।গাড়িতে উঠেছি। আধাঘন্টা হয়ে গেল গাড়িতে ওঠার।
Sir we have set off our journey to hospital. Half an hour passed.
[02/07/2024, 09:17] PAJR PHR MODERATOR: Ami OPD te thakbo
I will be in OPD
[02/07/2024, 13:22] Patient Advocate 27M Abdominal Migraine: স্যার uni হাসপাতালের নিচে ache। এক নাম্বার গেটের সামনে
[2/07/2024, 13:41] Patient Advocate 27M Abdominal Migraine: স্যার uni ক্যান্টিনে বসে achen। অনেক খোঁজাখুঁজি করল কিন্তু pelo না কোথাও।
Sir he is sitting in the canteen, was searching but couldn't find you anywhere
[02/07/2024, 13:43] Patient Advocate 27M Abdominal Migraine: স্যার ওপিডি গিয়েchilo uni, ওপিডি ওখানে dekhlo কেউ নেই।
Sir he went to OPD but nobody was there
[02/07/2024, 14:12] PAJR PHR MODERATOR: ICU te chole ashun.Ami ekhane achi
Come to the ICU, I'm here
[02/07/2024, 14:13] Patient Advocate 27M Abdominal Migraine: স্যার এখানে কোন দিকে
Sir in which direction
[02/07/2024, 14:17] Patient Advocate 27M Abdominal Migraine: স্যার আইসির সামনে দাঁড়িয়ে
Sir he is standing in front of the ICU
[02/07/2024, 14:20] PAJR PHR MODERATOR: Thik ache. Ami aashchi
OKAY, I'M COMING
[02/07/2024, 16:24] PAJR PHR MODERATOR @paJRmember 6 @pajrmember 7 Is this long distance patient admitted?
Make his levetiracitam 1/2 twice a day and continue his clonazepam and ask him to take it one hour before dinner
Schedule him for an upper GI and lower GI endoscopy in khl tomorrow and prepare his bowel and arrange his ambulance. If required @Pajr_member can coordinate the logistics with patient_advocate_1 or @patient_advocate_2 Admin although it's something that is often done routinely. Find out the costs and ask the patient if they can afford it
[02/07/2024, 16:34] Pushed Communicator 1N22: Okay sir
[02/07/2024, 16:46] Patient Advocate 27M Abdominal Migraine: স্যার বলছিলাম যে এখানে এডমিট হলে কতদিন থাকতে লাগবে বললে ভাল হত।
Sir , how many days they have to stay here? Any idea?
[02/07/2024, 16:53] PAJR PHR MODERATOR: Apnar endoscopy ta kalker modhye hoye gele aro ek du din boro jore
If the endoscopy is done in the morning, it will take another 2-3 days to get the report.
[02/07/2024, 17:09] Patient Advocate 27M Abdominal Migraine: ok
[02/07/2024, 18:36] PAJR PHR MODERATOR: Also get his ultrasound, hemogram, LFT, RFT, urine cue, chest X-ray and abdominal x-ray
[02/07/2024, 18:37] Pushed Communicator 1N22: Ok sir
[02/07/2024, 19:59] PAJR PHR MODERATOR: Also a note for the gastro tomorrow:
His upper GI endoscopy is for his recent Dyspepsia
His lower GI endoscopy is for his hematochezia
Also get his PR proctoscopy done by the surgeons today and let me know
[02/07/2024, 20:04] PAJR PHR MODERATOR: Actually better than proctoscopy is to ask the patient to take a mobile phone image of his anal verge after squatting as demonstrated by one of our innovative patients here 👇
[02/07/2024, 21:30] Patient Advocate 27M Abdominal Migraine: স্যার পানি খাওয়ার পরে পেট এখন খুব ব্যাথা করতেছে
Sir after drinking water the stomach pain has started too much
[02/07/2024, 22:07] PAJR PHR MODERATOR: @pajr_member please ask them to also monitor his intake output strictly
[02/07/2024, 22:15] Pushed Communicator 1N22: Okay sir
[02/07/2024, 22:15] Pushed Communicator 1N22: He is not eating anything sir as he is having pain
[02/07/2024, 22:16] Pushed Communicator 1N22: Even on fluid intake he is having pain
[02/07/2024, 22:16] Pushed Communicator 1N22:
[02/07/2024, 22:17] Pushed Communicator 1N22: Sir he is having a bit problem with money will discuss with his father and brothers tomorrow
Will send all the blood investigations today and plan for khl visit on Thursday
[02/07/2024, 22:20] PAJR PHR MODERATOR: Yes share his creatinine
Monitor intake output chart
02/07/2024, 22:40 - Pushed Communicator 1N22:
[02/07/2024, 22:44] PAJR PHR MODERATOR: His mild anemia is likely due to blood loss from his hemorrhoids
Could you get him to click his anal verge by squatting and aiming his mobile phone at the anal verge as demonstrated here?👇
[02/07/2024, 22:55] Pushed Communicator 1N22: Sir Upper and lower GI endoscopy will cost nearly 9-10k
[02/07/2024, 22:59] PAJR PHR MODERATOR: Alright if they are unable to afford let's wait till Friday upper GI and get the procto photo asap
[02/07/2024, 23:00] PAJR PHR MODERATOR: Also ask him to share a mobile image of his early morning stools tomorrow here
[02/07/2024 23.04] PPM 3: Okay sir.
[03/07/2024, 09:30] PAJR PHR MODERATOR: Good 👏
Was the patient able to click his anal verge by squatting and aiming his mobile phone at the anal verge as demonstrated in the case report link above?
Also did you ask him to share a mobile image of his early morning stools tomorrow here?
[03/07/2024, 09:33] PAJR PHR MODERATOR: @PAJR MEMBER আপনি কি আপনার রোগীর সকালের মলের একটি মোবাইল ফোনের ছবি শেয়ার করতে পারেন যা সে আজ করেছে?
Can you share a picture of your patient's stool from this morning on mobile, which they did today?
[03/07/2024, 09:37] PAJR PHR MODERATOR: @PAJR MEMBER আপনার রোগীর রক্তক্ষরণ তার পাইলস এবং ফিসারের কারণে হয়েছে বলে মনে হচ্ছে
আপনি কি তাকে তার পায়ুপথে ক্লিক করতে বলতে পারেন প্রথমে মল ত্যাগ করার মতো বসে বসে এবং তারপরে মলদ্বার খোলার সময় তার মোবাইল ফোনটি লক্ষ্য করে এবং এখানে প্রদর্শিত একটি ছবি পেতে?👇
It seems that your patient's bleeding is due to their piles and fissures.
Can you ask them to take a picture of their anus with their mobile phone after defecation, and then show the image here?"
This text appears to be a request for a patient to take a photo of their stool or anus after a bowel movement, likely for medical examination or diagnosis purposes.
By meta AI
Your patient's blood loss appears to be due to his piles and fissure
Could you ask him to click his anal opening by first squatting as in passing stools and then aiming his mobile phone at the anal opening and obtaining a picture as demonstrated here?👇
[03/07/2024, 09:45] Patient Advocate 27M Abdominal Migraine: onar তো পায়খানার চাপই পাচ্ছে না ।
He is not getting any pressure in his rectum.
[03/07/2024, 10:04] Patient Advocate 27M Abdominal Migraine
[03/07/2024, 10:05] Patient Advocate 27M Abdominal Migraine: স্যার এখনই বাথরুম থেকে আসলো। ব্লাড আসছে বিরাট আসার পরে এখন জ্বালা করতেছে।
ব্যাথা করতেছে।
Sir he just came from bathroom, blood came a lot and too much paining
[03/07/2024, 10:13] PAJR PHR MODERATOR: Ok, have seen. Nothing to worry
[03/07/2024, 14:12] PAJR PHR MODERATOR: @pajrmember Prescribe an ointment like anobliss for his anal pain and also get his eeg today afternoon before we can stop his levetiracitam altogether
Aldd tablet amitriptyline 25mg one hour before dinner from today
He can meet me outside ICU between 2-4 today
[03/07/2024, 14:14] Pushed Communicator 1N22: Prescribed anobliss sir. Will try to get EEG done today sir
[03/07/2024, 14:49] Patient Advocate 27M Abdominal Migraine: null
[03/07/2024, 14:50] Patient Advocate 27M Abdominal Migraine: ওষুধ গুলো কিভাবে ব্যবহার korbe সকাল বেলা নিয়ে eseche এখনো কিছু বলেনি। কেউ কিছু বলতেই পারতেছে না।
How to use these medicines, he has bought it in the morning.
[03/07/2024, 15:38] PAJR PHR MODERATOR: Lal molom ta paikhanar dware lagaben byathar jonye Injection ta mone hoina dorkar habe. Ota ferot dewa jete pare
The red ointment can be used in the rectum area
The injection may not be needed, it can be returned
[03/07/2024, 15:38] PAJR PHR MODERATOR: @PAJR_MEMBER1 return the iv pantoprazole. It's not necessary
[03/07/2024, 15:38] PAJR PHR MODERATOR: Aajke khete perechen apnar patient?
Has your patient eaten today?
[03/07/2024, 16:23] Patient Advocate 27M Abdominal Migraine: আজকে শুধু স্লাস kheyeche সেরকম একটা অসুবিধা হয়নি। কিন্তু বেশি একটা খেতে ইচ্ছে করে না এখনো। খিদেটা এখনো নেই বললেই চলে, শুধু দুইটা পিস kheyeche।
Today he had eaten 2 slices, today he got no pain, but don't feel like eating,
Just ate 2 pieces
[03/07/2024, 16:25] Patient Advocate 27M Abdominal Migraine: লাল মলমটা দিনে কবার lagabe
How many times the red ointment has to use
[03/07/2024, 16:26] Patient Advocate 27M Abdominal Migraine: When to take the tab LONAZEF?[03/07/2024, 16:27] Patient Advocate 27M Abdominal Migraine: এটা কখন khabe?
খাওয়ার আগে না পরে ? দিনে কবার ?
[03/07/2024, 16:52] PAJR PHR MODERATOR: Ekbar khawar aage
One time before eating
[03/07/2024, 16:53] PAJR PHR MODERATOR: Aager oshudh guno bondho kore dile aaste aaste khide feere paben asha korchi
If he stop taking the previous medicines, hopefully he will feels like eating normally, and will get hunger slowly
[03/07/2024, 16:54] Patient Advocate 27M Abdominal Migraine: লাল মলমটা দিনে কবার lagabe ?
How many times the red ointment has to use?
[03/07/2024, 16:54] PAJR PHR MODERATOR: Byatha hole lagaben
Paikhanar aage pore
Whenever he feels pain, after or before stool
[03/07/2024, 16:55] Patient Advocate 27M Abdominal Migraine: ব্যথা তো পায়খানা হলেই হয়।
ব্লাড পড়ে ব্লাড পড়লে প্রচন্ড ব্যাথা হয় ।
আজকে ব্লাড পড়ছিল ফটো তো pathano ache।
The pain starts while stool, blood comes, today also blood came, picture already sent
[03/07/2024, 16:57] Patient Advocate 27M Abdominal Migraine: আগের ওষুধ গুলো তো সব বন্ধ করে dieche
Previous medicines all stopped
[03/07/2024, 17:55] Pushed Communicator 1N22: Ok sir
[03/07/2024, 17:56] Pushed Communicator 1N22: Will return sir
They might have brought it seeing the surgeons note
[03/07/2024, 18:19] Patient Advocate 27M Abdominal Migraine: স্যার আজকে ভাত খাওয়া যাবে কি
Sir, will he eat rice today
[03/07/2024, 18:29] PAJR PHR MODERATOR: Hain oboshyoi
Yes, of course
[03/07/2024, 18:30] PAJR PHR MODERATOR: Also start him on tablet tryptomer 10 mg one hour before dinner from tonight
[03/07/2024, 18:31] PAJR PHR MODERATOR: Paikhanar aage lagiye neben
Tarpor jodi paikhanar por byatha hoi tokhon abar lagiye neben
Here's a translation of the text by META AI: "If the rectal pain subsides, and then if the pain returns after defecation, apply the ointment again."
[03/07/2024, 18:34] Pushed Communicator 1N22: Ok sir
Returned pantop
Asked him to get tryptomer
[03/07/2024, 19:39] Pushed Communicator 1N22:
[03/07/2024, 21:24] Patient Advocate 27M Abdominal Migraine: স্যার আজকে তো একটু ভাত খাইলাম।
কয়দিনের মতন পেট ব্যথা আজকে করিনি। হালকা একটু পড়ছে কিন্তু বেশি করেনি। এখন খাই তো মোটামুটি ইচ্ছা করতেছে।
Sir today I ate rice, the stomach pain has reduced from before, and feels like eating more or less
[03/07/2024, 21:45] Patient Advocate 27M Abdominal Migraine: স্যার এখন পেটটা একটু ব্যাথা ভালোই করতেছে
Sir now the stomach is paining
[03/07/2024, 21:47] Patient Advocate 27M Abdominal Migraine: স্যার এখন প্রচুর ব্যাথা করতেছে।
Sir it's hurting a lot right now
[03/07/2024, 21:51] PAJR PHR MODERATOR: @PAJR_MEMBER ask @PAJR_MEMBER and or @PAJR_MEMBER or whoever is on ward duty to examine his abdomen while it's paining now
[03/07/2024, 21:52] Pushed Communicator 1N22: Okay sir
Ward sister called just now
He had rice it seems sir after which his pain aggravated
[03/07/2024, 21:53] Pushed Communicator 1N22: Tryptomer is not available sir
[03/07/2024, 21:55] PAJR PHR MODERATOR: Any amitriptyline preparation can be taken
[03/07/2024, 21:57] PAJR PHR MODERATOR: His abdomen needs to be examined and palpated to rule out inflammatory causes of abdominal pain
Non inflammatory medical causes of abdominal pain can include porphyria or even lead poisoning
[03/07/2024, 21:59] Pushed Communicator 1N22: Okay sir
[04/07/2024, 12:45] Patient Advocate 27M Abdominal Migraine: স্যার কালকে ভাত খাওয়াতে তো পেট ব্যাথা করেছিল। তো আজকে কি ভাত KHABE?
Sir stomach pain had started after eating rice yesterday, will he eat rice today
[04/07/2024, 12:49] Pushed Communicator 1N22
[04/07/2024, 12:52] Patient Advocate 27M Abdominal Migraine: স্যার আজকে খিদেও পাচ্ছে প্রচুর
Sir today he is feeling hungry too much
[04/07/2024, 12:56] PAJR PHR MODERATOR: Let's take the EEG again while he has the abdominal pain to rule out abdominal epilepsy
[04/07/2024, 12:57] PAJR PHR MODERATOR: Hain oboshyoi khaben Jaate amra bujhte paari byatha ta keno hocche Aebar jodi dupurer khawar por abar kore tahole oi somoi dupure abar gotokaaler EEG test ta kore dekhbo
Yes of course, as we know why the pain is occurring,
If it started paining after taking lunch, then again we will do the yesterday's EEG TEST
[04/07/2024, 12:58] PAJR PHR MODERATOR: Let him have good amount of rice at lunch as that appears to be precipitating his pain and let's repeat the EEG during the pain
[04/07/2024, 12:58] Pushed Communicator 1N22: Okay sir
[04/07/2024, 14:30] Patient Advocate 27M Abdominal Migraine: স্যার ভাত তো khelo কদিনের মতো ব্যথা আজকে করতেছে না। হালকা একটু করতেছে।
Sir he has taken rice, it's not paining like other days, just a little
[04/07/2024, 14:30] Patient Advocate 27M Abdominal Migraine: আজকে বেশি ভাত খাইনি অল্প kheyeche
Today he has taken Little rice
[04/07/2024, 14:31] Patient Advocate 27M Abdominal Migraine: খিদে এখনো আছে। পেট ভরে খাই নাই আজকে।
He is hungry, has not eaten fully
[04/07/2024, 14:32] Patient Advocate 27M Abdominal Migraine: কিছুক্ষণ পরে আরো ভাত খাওয়া যাবে ?একটু ভাত আর সবজি rekheche পরে খাওয়ার জন্য।
Can he take rice after some time? Has some roti and sabzi to eat later
[04/07/2024, 14:40] PAJR PHR MODERATOR: Hain oboshyoi
YES OFCOURSE
[04/07/2024, 14:49] Patient Advocate 27M Abdominal Migraine: ঠিক আছে।
OK
[04/07/2024, 14:49] Patient Advocate 27M Abdominal Migraine: এখন আর পেট ব্যাথা নেই।
STOMACH IS NOT PAINING
[05/07/2024, 12:47] Pushed Communicator 1N22:
[05/07/2024, 12:57] PAJR PHR MODERATOR: Have you showed his EEG to the neurologist?
Who reported the EEG?
[05/07/2024, 13:13] Pushed Communicator 1N22: Neurologist reported it sir
[05/07/2024, 13:23] Patient Advocate 27M Abdominal Migraine: স্যার ইনডোসকপি তো হল এখন কি খাওয়া যাবে? আর একটা কি বাকি আছে বলল ওটা চারটার পরে হবে। খিদে লাগছে তো
Sir, endoscopy is done, can he eat now? One more test is due, it'll be done after 4'o clock. He is hungry
[05/07/2024, 14:08] PAJR PHR MODERATOR: Ask him if this fits into abdominal migraine Share literature around abdominal migraine here first
[05/07/2024, 14:08] PAJR PHR MODERATOR: Ki baki ache?
What is left now?
[05/07/2024, 14:41] Patient Advocate 27M Abdominal Migraine: পায়খানা করার পর রক্ত আসে সেইটার জন্য কী পরীক্ষা করে সেটা বাকি আছে।
Blood comes after stool, that is left
[05/07/2024, 16:10] Patient Advocate 27M Abdominal Migraine:
[05/07/2024, 16:21] PAJR PHR MODERATOR: Khete paren
[05/07/2024, 18:36] Patient Advocate 27M Abdominal Migraine: স্যার ইন্ডোসকপি করার পর থেকে মাথাটা ব্যাথা করতেছে। যত রাত হচ্ছে ততও ব্যথাটা বেশি হচ্ছে।
Sir, after Endoscopy he got headache as the night goes on, the pain increases
[05/07/2024, 19:13] Patient Advocate 27M Abdominal Migraine: স্যার মাথাটা ব্যাথা করতেছে স্যার
Sir my head is aching
PAJR PHR MODERATOR: @PAJR_MEMBER @PAJR_MEMBER Please start him now on tablet P650 6 hourly till tomorrow
Ensure that he's getting tablet amitriptyline 10mg one hour before dinner now
[05/07/2024, 19:22] Pushed Communicator 1N22: Okay sir
[05/07/2024, 19:24] PAJR PHR MODERATOR: onar মাথাব্যথার জন্য, আমি আমাদের কর্তব্যরত ডাক্তারদের জানিয়েছি যে আপনি আগামীকাল পর্যন্ত প্রতি 6 ঘন্টা পর পর ট্যাবলেট প্যারাসিটামল 650 মিলিগ্রাম এবং আজ রাতের খাবারের এক ঘন্টা আগে ট্যাবলেট অ্যামিট্রিপটাইলাইন 10 মিলিগ্রাম যত তাড়াতাড়ি সম্ভব খাওয়া শুরু করুন।
For his headache I've told the doctors who are on duty to give PARACETAMOL 650 mg after 6 hours and try to take Amitriptyline 10 mg before 1 hour of dinner as soon as possible
[05/07/2024, 19:24] PAJR PHR MODERATOR: Reviewed literature on abdominal migraine?
[05/07/2024, 19:25] PAJR PHR MODERATOR: Did you talk with him regarding this patient's diagnosis? Ask him to write a note on the file and share it with me
[05/07/2024, 19:56] Patient Advocate 27M Abdominal Migraine: স্যার মাথা ব্যথা টা অটোমেটিক কমে গেল।
Sir the headache has stopped automatically
[05/07/2024, 19:57] Patient Advocate 27M Abdominal Migraine: এখন ভালো লাগছে
He is feeling better now
[05/07/2024, 19:58] Patient Advocate 27M Abdominal Migraine: ইন্ডাস কপি করার সময় বমি korechilo তাই মনে হয় মাথা ব্যথা করছিল। এখন আর নেই
He vomitted while the endoscopy test, maybe that's why the headache started, now the headache has stopped
[05/07/2024, 20:19] - Patient Advocate 27M Abdominal Migraine: <Media omitted>
[05/07/2024, 20:20]- Patient Advocate 27M Abdominal Migraine: স্যার এটা ki anbe? ।কখন খেতে হবে।Sir will he bring it? When to take?
[05/07/2024, 20:46] - Pushed Communicator 1N22: Abdominal migraines (AM) are unprovoked episodes of central abdominal pain associated with migraine symptoms such as sensory hypersensitivities to light and sound, vomiting, nausea, acute headaches, and general pallor.
While common in children, AM is considered a rare diagnosis in adults.
Associated with childhood migraines.
Associated with decreased GI motility.
Symptoms resolved with sumatriptan. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10118217/
[05/07/2024, 20:56] - Pushed Communicator 1N22:
[05/07/2024, 20:57] - PAJR PHR MODERATOR: Shudhu khub beshi byatha hole
If there is too much pain
[05/07/2024, 20:58] - PAJR PHR MODERATOR: Although rare this diagnosis fits the patient here like a glove?
[06/07/2024, 07:54]- Patient Advocate 27M Abdominal Migraine: স্যার আজকে তো পুরোপুরি সুস্থ লাগতেছে। কোন অসুবিধা লাগতেছে না আজকে খুব ভালো লাগতেছে শরীরটা।
Sir today he feels totally fine, he is not facing any problem, feeling much better
[06/07/2024, 09:53] - PAJR PHR MODERATOR: Thik ache. Kichu din khawa dawa normal korun. Dekha jak abar kono asubidhe hoi kina
Ok, eat normally for somedays, let's see if he faces any problem
[06/07/2024, 09:54] - Patient Advocate 27M Abdominal Migraine: Ok
[06/07/2024, 13:01] Patient Advocate 27M Abdominal Migraine: ওষুধ গুলো তো pelo না এখানে স্যার।He didn't find the medicine here
[06/07/2024, 13:02] Patient Advocate 27M Abdominal Migraine: আজকে আর আমার কোন রকম অসুবিধা নাই একদম ।
Today there is no problem
[06/07/2024, 13:48] Patient Advocate 27M Abdominal Migraine: এই ওষুধগুলো পড়ে কিনে খেলে কি অসুবিধা হবে ? এই ওষুধগুলো kinbe কিনা ?
If he buys these medicines later will there be any problem?
Will he buy these medicines?
[06/07/2024, 20:30] Patient Advocate 27M Abdominal Migraine: <Media omitted>
[06/07/2024, 20:56] PAJR PHR MODERATOR: Aei oshudh guno ami likhini. Aager daktar likhechilo.
Aeguno bondho kore goto kal jeta likhechilam sheta khete paren
I didn't recommend these medicines, the previous doctor recommended, you can stop taking this medicines and take what I have written
[06/07/2024, 20:57] PAJR PHR MODERATOR: Eta apni aageo khacchilen. Eta hothath bondho korte chaini bole eta apatoto raate ekbar nite paren
You were taking it before, I didn't want to stop it suddenly, can take one doze at night
[06/07/2024, 20:57] PAJR PHR MODERATOR: Khawar pore
Dine ekta dim khete paren
After eating, he can take an egg per day
[06/07/2024, 20:59] PAJR PHR MODERATOR: He's not getting tablet amitriptyline 10mg one hour before dinner?
[06/07/2024, 21:0] Pushed Communicator 1N22: I told the sister to give it daily sir will confirm sir
[07/07/2024, 00:31] Patient Advocate 27M Abdominal Migraine: Which time given tablet sir
[07/07/2024, 07:31] PAJR PHR MODERATOR: Raate khawar ek ghonta aage
Eta roj noi. Shudhu jedin matha byatha hobE
Rojkar jonye onyo tablet amitriptyline 10mg raate khawar aage nite bolechilam
@PAJR_MEMBER hasn't he still gotten his amitriptyline? one hour of taking dinner, this is not for everyday, just he has to take whenever he feels headache, for everyday already told to take AMITRIPTYLINE 10 mg before eating dinner
[07/07/2024, 09:10] Pushed Communicator 1N22: Sir he is taking amitriptyline daily at night sir
[07/07/2024, 09:30] PAJR PHR MODERATOR: Good Tell him clonazepam is only for stress headache days
[07/07/2024, 09:33] Pushed Communicator 1N22: Okay sir
[07/07/2024, 09:51] Patient advocate 23F Weight Gain joined using this group's invite link
[7/7, 1:18 PM] Patient Advocate : কালকেও পায়না korechilo রক্ত আসেনি ।স্যার আজকে পায়খানা korechilo কিন্তু কোন রক্ত বেরোয়নি। ব্যাথা হালকা একটু করেছিল বেশি না । তাই ফটো tole ni ।
Here's a translation of the text by @META AI
Yesterday, I had stool but no blood came out. Sir, today he had a bowel movement but there was no blood. The pain was mild, not severe, that's why he didn't take photo."
[7/7, 1:23 PM] PaJR PHR Moderator: Thik ache. Bhalo bhabe khele paikhana shob somoi bhalo habe
Ekhane dekha jay ki bhabe khawa uchit 👇
If he maintains good food habits, always stool will pass normally
Here is the written how to maintain good food habit ☝🏻
[7/7, 3:41 PM] patient advocate : স্যার আজকে এখন টয়লেটে giyechilo একটু পায়খানা টাইট হয়েছিল।ব্লাড আসেনি কিন্তু হালকা ব্যথা করতেছে এখন
Here's a translation of the text by META AI:
Sir, he went to the toilet just now and passed a small amount of stool, which was tinged with mucus. There was no blood, but he is experiencing mild pain right now.
[7/7, 5:36 PM] Patient advocate 2: স্যার বলছিলাম onar হাতে স্যালাইনের যে সূচটা লাগানো আছে। সেটা কি এখন খোলা যাবে ?হাতটা ব্যাথা করতেছে ওই জায়গায়। খুললে ভালো হতো।
Here's a translation of the text:
Sir, he was saying that the saline needle inserted in his hand is still there. Can it be removed now? The hand is painful at that spot. It would be better if it's removed.
[7/7, 5:40 PM] PaJR PHR Moderator: Hain
Sister ke janiye khule nin
Yes, after telling the sister to open it
[7/7, 5:40 PM] +91 patient advocate: সিস্টাররা বলছে যদি আরো কোন ইনজেকশন লাগে তাই তারা খুলছে না। সেজন্য আমি বললাম
Sister is saying if other injection needed that's why they are not opening, and that's why he is asking
[7/7, 5:41 PM] PaJR PHR Moderator: @pajr_member who's on duty?
Please ask them to prescribe him liquid paraffin to be taken tid from today. Also ask the current ward staff to remove his cannula asap
[7/7, 7:36 PM] Pajr_member: @Pajr_member is on duty sir
[7/7, 7:36 PM] PAJR_MEMBER: Informed her sir.
স্যার ম্যাম বলেছিলে এই ফাইলটা নিয়ে আসতে কিন্তু আমি ফার্মেসিতে গিয়ে amar patient dekhen এই ফাইল নেই অন্য একটা ফাইল দিয়েছে। উপরে যে ফাইলটার ছবি pathano সেটা দিয়েছে. এখন আর এক ডাক্তার ম্যাম এসে বলছে যে ফাইল সে ফাইল না।
এখন ki kora jay।
এটা রিটার্ন korte hobe? Naki অন্য দোকান থেকে নিয়ে aste hobe ? না এটা nilei hobe?
Sir Doctor ma'am has told to bring this medicine, but when my patient had gone to the farmacy he saw this medicine was not available, so they provided another medicine. The above mentioned file was provided. Now another doctor came and told that this medicine is not that medicine.
Now what to do? Will my patient return it or bring it from another farmacy or keep it ?
PAJR PHR MODERATOR: Etai bhalo. Aetai khete pare
This is ok, he can take it
[7/8, 3:09 PM] patient advocate: স্যার amar patient এখন টয়লেট থেকে eseche।
পায়খানার সঙ্গে ব্লাড আসেনি, পায়খানা রাস্তা ব্যথা করেনি জ্বালাও করেনি।
পায়খানা নরমাল হয়েছে। কোনরকম জ্বালা হয়নি।
Sir My patient has come from toilet, blood has not come with stool, rectum was not paining or burning, stool was also normal, he didn't feel like burning
[7/8, 4:29 PM] PaJR PHR Moderator: @patient_advocate 3 @patient_advocate2
মোবাইল ফোন টেক্সট ভিত্তিক যোগাযোগে এই রোগীর দক্ষতা দেখে আমি বিস্মিত। এখানে 2000 কিলোমিটার থেকে হাসপাতালে আসার পর প্রথম দিনেই তিনি এই হাসপাতালে আমার সাথে একবারই দেখা করেছেন কিন্তু তার পরে তিনি একা এই PaJR গ্রুপে পাঠ্য ভিত্তিক যোগাযোগের মাধ্যমে খুব ভালভাবে পরিচালনা করেছেন!
তিনি আমাদের সবচেয়ে দক্ষ PaJR ব্যবহারকারীদের একজন এবং আমরা আশা করি যে তিনি অদূর ভবিষ্যতে PaJR এর মাধ্যমে আমাদের কাছে পৌঁছাতে অন্যান্য রোগীদেরও সাহায্য করবেন।
@~~>• @PaJR Coordinator I am amazed to see this patient's skill in mobile phone text based communication. After coming here to the hospital from 2000 kms he has met me only once in this hospital on the very first day but after that he has managed very well through text based communication on this PaJR group alone!
He is one of our most skilled PaJR users and we hope he will also help other patients to reach out to us through PaJR in the near future.
[7/8, 4:30 PM] patient advocate 1 : হ্যাঁ স্যার: অবশ্যই স্যার
Yes sir and of course.
[7/9, 9:12 AM] patient advocate 1: স্যার সকালবেলা পায়খানা থেকে eseche রক্ত পড়েনি জ্বালা যন্ত্রনা কিছু করেনি ব্যথাও করেনি।
এখন uni খেতেও পারতেছি ঠিকমত।
বারবার খিদে লাগে।
খেতে একটু দেরি হলে পেট ব্যাথা করে খেলে আবার ঠিক হয়ে যায়।
Sir he came from bathroom at morning, blood has not come, there was not burning and paining. Now he can eat normally and feels hungry often. If it delays to taking food, stomach starts burning, again get normal
[7/9, 9:24 AM] PaJR PHR Moderator: @Patient_advocate3 Patient ke janaben jate uni khawa always time a time a korben
Paikhanao roj time a time a jate jaan
Tahole unar somosya aaste aaste puropuri nirmul hote pare
@patient_advocate3 tell the patient that he should take meal time to time and if he pass stool regularly at a time, all his problems can be completely resolved.
[7/9, 9:24 AM] patient_advocate1: ঠিক আছে স্যার,
Ok sir
[7/9, 10:59 PM] PaJR PHR Moderator: https://24fpatientblog.blogspot.com/2024/07/28m-abdominal-migraine-1-month-headache.html
[7/10, 10:30 AM] patient_advocate1: স্যার বলছিলাম যে দুদিন ধরে amar patient ke এসে ডাক্তার দেখছে না।
কোন ডাক্তারই দেখছে na onake।
কিছু বলেও না।
শুধু শুয়ে শুয়ে ache বেডে।
খাবার সময় হলে khay আর শুয়ে thaken।
Sir from 2 days no doctor has come to watch him .
Nobody tells nothing, he always lies on the bed and takes his meal when meal time. Always he lies on the bed
[7/10, 10:32 AM] PaJR PHR Moderator: Ami OPD te achi. Aeshe dekha kore nin. Onar shob jana geche ebong treatment o shuru kora hoyeche tai hoito bakira nishchinto hoye geche
I'm here at OPD, come and meet me, we got to know all his problems, and treatment has started, may be that's why everyone is relieved
[7/10, 10:32 AM] PaJR PHR Moderator: @Pajr_member What about the neurologist opinion for his EEG and triangulation of the abdominal migraine diagnosis
[7/10, 10:39 AM] pajr_member: Discussed with neurologist sir
Sir will come tomorrow
He said he will review tomorrow
[7/10, 10:48 AM] patient_advocate1: স্যার uni রুম খুঁজেই পেলাম না।
Sir my patient has not found your room
[7/10, 10:50 AM] PaJR PHR Moderator: Okhane boshte bolun OPD r kache. Ami onake khuje nebo
Please tell him to sit there , I'll find him
[7/10, 11:12 AM] patient advocate 1: স্যার uni OPD খুঁজে pelo না।
তাই নিজের রুমে চলে আসলাম।
আমি এখন বেডে ache ।
Sir my patient didn't find OPD, that's why came to his room, and now he is lying on the bed in his room
[7/10, 11:24 AM] PaJR PHR Moderator: @pajr_member Please ask an intern to bring him to me in the OPD. He's unable to find it on his own. He's currently in his bed
[7/10, 11:32 AM] pajr_member: Sending him sir
[7/10, 11:49 AM] PaJR PHR Moderator: Thanks
Had a good meeting
We can discharge him tomorrow after the neurologist's notes and re-evaluation of the EEG
[7/10, 11:50 AM] PAJr_member: Okay sir
[7/10, 9:55 PM] patient_advicate1: বলছিলাম onar ঘুমটাই পাচ্ছে না ঠিকমতো শুয়ে ache ঘুম ধরতেছে না।
ঘুমের ওষুধ টা kheyechilo যেটা ঘুমের ওষুধ ছিল।
তবুও জানি না কেন ঘুম ধরছে না।
He is having trouble in sleeping, he is lying properly, but can not sleeping normally,
He took the sleeping peel but still having trouble with sleeping
[7/10, 9:55 PM] patient _advocate: খাবার আগেই kheyechilo।
He had taken meal before
[7/10, 10:05 PM] PaJR PHR Moderator: Khabar kotokkhon aage?
How long ago he had taken food?
[7/10, 10:06 PM] patient_advocate1: এক ঘন্টা আগে
One hour ago
[7/10, 10:06 PM] patient_advocate1: সাতটায় ওষুধ kheyeche।
আটটায় ভাত dieche ।
তখনই শুয়ে poreche কিন্তু ঘুম ধরতেছে না।
He had taken medicine at 7 , had taken dinner at 8 then he lied , but having trouble in sleeping
[7/10, 10:15 PM] PaJR PHR Moderator: Ekhane saradin are kono porishrom nei bole
There is no hardwork here that's why having trouble in sleeping
[7/11, 10:22 AM] pajr_member: Neuro sir told abdominal migraine is more often associated with vomitings, and it is more common in paediatric age group
[7/11, 10:24 AM] pajr_member: What about EEG?
[7/11, 10:37 AM] PaJR PHR Moderator: Migraine in general can be associated with vomitings and yes as @pajr_member pointed out his valuable inputs are necessary to correlate the EEG with his symptoms in the sense if he may like to share any opinion about the possibility that the EEG findings may have some correlation
[7/11, 10:49 AM] pajr_member: About 3% people can have epileptogenic foci on EEG, but it is not reliable
[7/11, 11:28 AM] patient_advocate1: স্যার uni কি আজকে তোমার সঙ্গে দেখা করতে pare?
Sir will he meet with you today?
[7/11, 11:39 AM] PaJR PHR Moderator: Oboshyoi
Of course
[7/11, 11:40 AM] patient_advocate: কখন ?
কোথায় ?
When and where?
[7/11, 11:42 AM] PaJR PHR Moderator: Aekhon
Goto kal jekhane dekhiyechilen
Now, tell him to meet me where he met yesterday
[7/11, 11:43 AM] +patient_advocate1: thik ache asche
Ok he is coming
[7/11, 11:45 AM] pajr_member: Sir advised to start him on sodium valproate
[7/11, 11:50 AM] patient_advocate1: স্যার এখন তো কালকের এখানে বসে ache
Sir now he is sitting where he met with you yesterday
[7/11, 11:50 AM] PaJR PHR Moderator: Why?
He feels those epileptogenic foci that 3% of normal people can have needs treatment in this patient who never had any history of seizures.
[7/11, 11:53 AM] pajr_member: He asked to stop leviteracetam and to start sodium valproate for his headache
[7/11, 11:57 AM] PaJR PHR Moderator: We have started him on amitriptyline and he's doing well on it so far.
I think we'll continue amitriptyline rather than add a new drug.
Please prepare the discharge summary accordingly.
[7/11, 11:59 AM] pajr_member: Okay sir
[7/11, 12:11 PM] patient _advocate1 : স্যার uni 78 নম্বর ওয়ার্ড এর এখানে বসে ache।
Sir he is sitting beside ward no 78
[7/11, 12:17 PM] PaJR PHR Moderator: Please discharge him before lunch as they have to go a long way to go today
[7/11, 3:01 PM] patient_advocate 1: স্যার বলছিলাম এখনো তো uni ডিসচার্জের কাগজ হাতে pelo না।
এতটা পথ যেতে লাগবে দেরি হয়ে যাচ্ছে।
দয়া করে বলুন না একটু তাড়াতাড়ি ছাড়তে।
প্লিজ
Sir , he has not gotten the discharge papers till now,
He has to go a long way , getting late ,
Please tell them to leave him as early as possible please sir
Discharge summary :
Age/Gender: 28 Years/Male
Address:
Discharge Type: Relieved
Admission Date: 02/07/2024 04:24 PM
Diagnosis
LOWER GI BLEED SECONDARY TO FISSURE IN ANO INTERNAL HAEMORRHOIDS
ABDOMINAL MIGRAINE
Case History and Clinical Findings
C/O BLEEDING PER RECTUM SINCE 4 MONTHS
HOPI : PATIENT WAS APPARENTLY ASYMPTOMATIC 4 MONTHS BACK THEN DEVELOPED BLEEDING PER RECTUM Aggravated SINCE LAST 1 MONTH , FRESH BLOOD
PAIN ABDOMEN SINCE 1 MONTH IN EPIGASTRIC , UMBILICAL REGION &BURNING IN TYPE AGGRAVATED WITH FOOD IN TAKE
H/O LOSS OF APETTITE SINCE 1 MONTH NO H/O VOMITINGS ,FEVER
NO HISTORY OF CHEST PAIN , BREATHLESSNESS, PEDAL EDEMA, ORTHOPNEA, PND NO H/O COUGH , COLD , DECREASED URINE OUT PUT
PAST HISTORY:
NOT K/C/O DM, HTN, CVA, CAD, THYROID DISORDERS, TB, ASTHMA PERSONAL HISTORY:-
APETITE- LOST
BOWEL- REGULAR WITH BLOOD IN STOOLS BLADDER- NORMAL
ALLERGIES-NIL ADDICTIONS-NIL
FAMILY HISTORY: -NOT SIGNIFICANT
GENERAL EXAMINATION: -VITALS AT ADMISSION PATIENT IS CONSCIOUS, COHERENT, CO-OPERATIVE
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA. BP-100/80 MMHG
PR-82 BPM RR-16 CPM
TEMP-AFEBRILE SPO2:-98% ON RA
SYSTEMIC EXAMINATION CVS-S1 S2 HEARD
RS- NVBS HEARD, NO WHEEZE
P/A:-SOFT, TENDERNESS IN EPIGASTRIC REGION CNS-NO FOCAL NEUROLOGICAL DEFICITS NOTED
SURGERY REFERAL DONE ON 5/7/24 I/V/O BLOOD IN STOOLS ADVICE: CBP.STOOL OCCULT BLOOD, UPPER GI ENDOSCOPY PLENTY OF ORAL FLUIDS
INJ PAN TOP 40MG IV BD
SYP SUCRALFATE O 10 ML PO PID
SITZBATH WITH BETADINE SOLUTION FOR 5 MINS TID OINTMENT ANOBLISS FOR L/A
REVIEW WITH REPORTS
SURGERY REFERAL DONE ON 6/7/24:
ADVICE: SITZBATH, FIBER RICH DITE TO CONTINUE ANOBLISS OINTMENT FOR ANAL FISSURE
GASTROENTEROLOGY REFERAL WAS DONE ON 5/7/24 I/V/O PAIM ABDOMEN AFTER FOOD INTAKE:
ADVICE: UGIE WITH FASTING, PLENTY OF ORAL FLUIDS, INJ. PAN 40 MG IV/BD, SYP SUCRALFATE 10ML PO/TID, SITZ BATH WITH BETADINE FOR 15 MINS, OINT.ANOBLISS L/A.
COURSE IN HOSPITAL:
A 28 YR OLD MALE WHO IS ON ANTIEPILEPTIC MEDICATION CAME WITH CHIEF COMPLAINTS OF BLEEDING PER RECTUM SINCE 4MONTHS, Aggravated SINCE LAST ONE MONTH, ASSOCIATED WITH FRESH BLOOD, PAIN ABDOMEN SINCE ONE MONTH IN EPIGASTRIC AND UMBILICAL REGION, BURNING IN TYPE Aggravated WITH FOOD INTAKE. ON EXAMINATION TENDERNESS PRESENT IN EPIGASTRIC REGION. USG ABDOMEN SHOWED CHOLELITHIASIS, MILD SPLENOMEGALY, PROMINENT MESENTERIC LYMPHNODES. GENERAL SURGERY REFERAL WAS DONE IN VIEW OF BLEEDING PER RECTUM, PR EXAMINATION SHOWCK POSITION,ADVISED OINT ANOBLISS, SITZ BATH WITH BETADINE SOLUTION FOR 15MINS, THRICE A DAY,FIBRE RICH DIET. EEG WAS DONE WHICH SHOED FISSURE AT 6 O CLOCK POSITION, PROCTOSCOPY SHOWED INTERNAL HEMORRHOIDS AT 7 O CLOCK, 11 OCLOWEDGASTROENTEROLOGY REFERAL WAS DONE IN VIEW OF PAIN ABDOMEN, UGIE SHOWED NORMAL STUDY. EEG SHOWED BIFRONTAL EPILEPTIC FOCUS. TREATED WITH NSAIDS, ANTIDEPRESSANTS. PATIENT WAS IMPROVED SYMPTOMATICALLY AND DISCHARGED IN HEMODYANAMICALLY STABLE CONDITION
Investigation
ON 02-07-2024
COMPLETE URINE EXAMINATION (CUE) :
COLOUR Pale yellow APPEARANCE Clear
REACTION Acidic SP.GRAVITY 1.010
ALBUMIN Trace SUGAR Nil BILE SALTS Nil
BILE PIGMENTS Nil PUS CELLS 2-3
EPITHELIAL CELLS 2-3 RED BLOOD CELLS 1-2 CRYSTALS &CASTS Nil
AMORPHOUS DEPOSITS Absent
BLOOD UREA: 19 mg/dl
SERUM CREATININE 1.2 mg/dl
SERUM ELECTROLYTES (Na, K, C l):
SODIUM 137 mmol/L 145-136 mmol/L
POTASSIUM 3.7 mmol/L 5.1-3.5 mmol/L
CHLORIDE 102 mmol/L 98-107 mmol/L
LIVER FUNCTION TEST (LFT)
Total Bilurubin 1.77 mg/dl Direct Bilurubin 0.45 mg/dl SGOT(AST) 15 IU/L
SGPT(ALT) 10 IU/L
ALKALINE PHOSPHATASE 138 IU/L TOTAL PROTEINS 6.5 gm/dl
ALBUMIN 4.37 gm/dl
A/G RATIO 2.05
HEMOGRAM:
HAEMOGLOBIN 10.3 gm/dl TOTAL COUNT 6,200 cells/cumm NEUTROPHILS 50%LYMPHOCYTES 40%EOSINOPHILS 04%MONOCYTES 06%BASOPHILS 00%PCV 28.9 vol %M C V 52.6FLM C H
18.8pgM C H C 35.6%RBC COUNT 5.4PLATELET COUNT 2.3lakhs/cu.mm
USG ON 2/7/24
IMPRESSION: CHOLELIATHIASIS, MILD SPLENOMEGALY, PROMINENT MESENTRIC LYMPHNODES
UGIE DONE ON 5/7/24: NORMAL STUDY
Treatment Given (Enter only Generic Name)
TAB BUSCOPAN IV BD
TAB CLONAZEPAM 1MG PO/HS
TAB AMITRYPTILINE 25MG PO/OD 1 HOUR BEFORE DINNER TAB LEVITERACETAM 250MG PO/BD
TAB PCM 650 MG PO/QID
SYP CREMFFIN 10ML PO/TID OINT ANOBLISS FOR L/A
SITZ BATH WITH BETADINE SOLUTIN FOR 15 MINS 3 TIMES A DAY
Advice at Discharge
TAB. LEVITERACETAM 250 MG PO/BD
TAB. AMITRIPTYLINE 25 MG PO/HS ONE HOUR BEFORE DINNER TAB. CLONAZEPAM 1MG PO/HS
SYP. CREMAFFIN 15 ML PO/HS ANOBLISS OINTMENT FOR L/A
SITZ BATH WITH BETADINE SOLUTION FOR 15 MINS THRICE DAILY
Follow Up
REVIEW TO GM OPD AFTER 2 WEEKS.
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: 08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date Date:11/7/24 Ward:MGMW Unit:II
[7/13, 8:37 PM] patient advocate 1: স্যার আজকে আমার patient er মাথা ব্যাথা করতেছে মোটা মুটি ভালই ব্যাথা করতেছে।
Sir today my patient is having too much headache
[7/13, 8:42 PM] PaJR PHR Moderator: Tablet Paracetamol 650 mg proti 6 ghonta por por dite shuru kore din ebong raater amitriptyline 25 mg ta aekhoni khawar aage kheye nite bolun
Ask to take him Paracetamol 650 mg in every 6 hours and take Amitriptyline 25 mg before eating dinner now
[7/13, 8:49 PM] patient advocate 1: ঠিক আছে স্যার।
Ok sir
[7/18, 9:34 AM] patient advocate 1: স্যার বলছিলাম আজকে আমার patient er জ্বর আসছে।
সকালবেলা প্যারাসিটামল kheyrchilen ।
তবুও জ্বর কমতাছে না।
Today my patient feels fever
He took Paracetamol at morning still fever has not gone
[7/18, 10:16 AM] PaJR PHR Moderator: Aapnar patient ke janaben jate proti char char ghonta jor ta thermometer diye mepe janaben ebong proti 6 ghonta por por paracetamol 650 khete paren tabe khawar aage jor ta mepe neben ebong amader ekhane janaben
Tell your patient to count the fever by Thermometer in every 4 hours and let us know in the group
And he can take Paracetamol 650 mg but ask him to count the fever before eating and let us know
[7/19, 6:27 AM] patient advocate 1: স্যার পেশেন্টের পাতলা কমতেছে না।
ইজিলাক্স খাওয়া বন্ধ করেছি তবুও।
ইজিলেক্স দুই দিন ধরে বন্ধ আছে।
পায়খানা কমছে না।
Sir His loose motion is not curing, he has stopped to take ESILEX, still not stopped his loose motion. He has stopped the ESILEX for two days but loose motion is still not curing.
থেকে 10 বার।
Patient has stopped taking above medicine from 2 days still loose motion had not stopped daily 8-10 times a day
[7/19, 8:26 AM] Patient Advocate 1: স্যার এখন মাপা হইল ৯৯.৩ দেখাচ্ছে থার্মোমিটারে।
Sir, just noted the temperature 99.3 ° in Thermometer
[7/19, 8:34 AM] patient advocate 1: পাতলা পায়খানা টা তো বন্ধই হচ্ছে না পেশেন্টের।
কি করবে এখন ?
The loose motion is not stopping anyhow
What to do now?
[7/19, 8:44 AM] PaJR PHR Moderator: Paikhanar chobi share korun
Share the picture of the stool
[7/19, 8:44 AM] PaJR PHR Moderator: Proti char char ghonta mepe janaben
Count the fever in every 4 hour.
[7/19, 9:33 AM] PaJR PHR Moderator: Recently kono ekta jaigai khawar por hoyeche? Aro jara apnar patient er saathe kheyechhilen taader o hoyeche?
Recently happened by eating somewhere? Those who ate with your patient also suffered?
[7/19, 9:34 AM] patient advocate 1: না।uni শুধু কালকে আনারস kheye chilen জ্বর আসছিল সেজন্য
No, he had eaten just pineapple yesterday as he suffered from Fever
[7/19, 9:34 AM] patient advocate 1: তার আগের থেকে পাতলা পায়খানা ছিল।
He was suffering from loose motion before that
[7/19, 9:34 AM] PaJR PHR Moderator: Hain anarosh guno dekha jacche
Yes the pineapples are visible
[7/19, 9:34 AM] PaJR PHR Moderator: Kabe theke?
From when?
[7/19, 9:35 AM] patient advocate 1: আজকে নিয়ে তিনদিন থেকে
3 days including today
[7/19, 9:36 AM] PaJR PHR Moderator: Aapnar patient er goponiyotar jonye patient ke naam dhore daakben na
@pajr_member unar video te patient er naam dekha jacche! Video guno te jaate patient er naam na dekha jai sheta ektu unar mobile phone check kore adjust kore dewa jabe?
In his video his name is visible! Can it be adjusted by checking his phone so that his name can't be visible?
[7/19, 9:37 AM] PaJR PHR Moderator: Aekhon baki khabar khete icche korche?
Is he willing to eat something?
[7/19, 9:37 AM] patient advocate 1: জ্বরের জন্য কিছু খেতে মন চাচ্ছে না।
He is not willing to eat anything due to fever
[7/19, 9:40 AM] PaJR PHR Moderator: Bhoyer kichu nei.
Apnar local PHC r daktar ke janiye:
1) Jorer jonye proti 6 ghonta ontor ontor paracetamol 650 mg dine char bar shudhu aajker jonye nite paren.
Proti char char ghonta por por jor ta mepe amader janaben
2) Diarrhoea r jonye PHC theke ORS powder niye alpo alpo khete paren
[7/19, 9:40 AM] PaJR PHR Moderator: Anarosh o noi?
Don't worry,
He can take suggestion from local PHC doctor
1. He can take Paracetamol 650 mg in every 6 hours 4 times a day today
Note the temperature in every 4 hour and let us know in this group
2. For DIARRHOEA he can take Little ORS powder from local PHC
[7/19, 9:40 AM] pajr member: yes
[7/19, 9:41 AM] pajr member: checking on it
[7/19, 9:41 AM] patient advocate 1 : না
No
[7/19, 9:47 AM] patient advocate 1: মুখটা কেমন তেতো হয়ে গেছে কিছু ভালো লাগে না খেতে।
Tongue has become bitter that's why he is not willing to eat anything
[7/19, 9:48 AM] PaJR PHR Moderator: Tahole ORS powder alpo alpo chamoch a chumuk diye khete bolun
Then tell him to take ORS powder in a spoon and eat little
[7/19, 9:48 AM] patient advocate 1: ঠিক আছে স্যার
Ok sir
[7/19, 9:52 AM] PaJR PHR Moderator: Would it be possible to YouTube all the above videos after full deidentification and putting a new name to the channel?
You can utilise our pre existing channel name for this, which is Case based blended learning ecosystem, user driven healthcare, PaJR
Check out the previous playlisted mixed bag archive here👇
[7/19, 10:09 AM] pajr_member : It can be done , for this the access of this channel is needed
[7/19, 10:25 AM] PaJR PHR Moderator: No the one that I shared above is just a playlist made of multiple channels by different YouTubers and it's itself not a channel
You need to make a separate channel of your own to showcase our PaJR videos. You can call it "Patient centred PaJR, CBBLE, UDHC channel and explain the full forms in the description box borrowing from the glossary here 👇
[7/19, 10:31 AM] pajr_member : Ok.. I'll do it
[7/19, 11:27 AM] patient advocate 1: স্যার এখন maplo থার্মোমিটারে ৯৮.৩ দেখাচ্ছে।
Sir now the temperature is showing 98.3
[7/19, 11:35 AM] PaJR PHR Moderator: Bhalo
Good
[7/19, 11:45 AM] patient advocate 1: স্যার পায়খানাটা তো কমতেছে না।
সম্মানী হয়েই চলছে।
Sir stool is not stopping,
[7/19, 11:48 AM] PaJR PHR Moderator: Paikhana ta puro tai ekta plastic kimba kaacher bashon a korun jaate koto ta paikahna holo sheta 24 ghontai ojone kore dekha jai
Ebong proti bar paikhana ta bashon a tolar aage protibar paikhana tar chobi pathaben. Video na pathaleo cholbe
Everytime use a glass or plastic container while stool and weight it so that in 24 hours how much stool is happening it can be seen
[7/19, 1:07 PM] PaJR PHR Moderator: But be careful to not use your old email address that you use for your previous channels. YouTube AI sometimes finds many of our medicine videos offensive and threatens to cancel our channel so best is open it fresh so that even if they cancel it won't matter. Again YouTube gives three chances before it's cancelled
[7/19, 1:15 PM] pajr_member : Ok
[7/19, 7:11 PM] patient advocate 1: স্যার এখন 96.9 থার্মোমিটারে দেখাচ্ছে।
Sir now it's showing 96.9 ° in the Thermometer
[7/20, 12:22 PM] patient advocate 1: স্যার আজকে onar পেটে প্রচন্ড ব্যাথা হচ্ছে।
Sir today his stomach is paining too much
[7/20, 12:24 PM] pati: সকালে ঘুম থেকে উঠে ভাত kheyeche
আলু ও সয়াবিনের সবজি দিয়ে।
প্রচুর ব্যাথা করতেছে স্যার।
He has eaten rice with alu and soyabin vegetable, it's paining too much
[7/20, 12:30 PM] patient advocate 1: স্যার প্রচন্ড ব্যাথা করতেছে।
Sir it's paining too much
[7/20, 12:35 PM] patient advocate 1: আনারস kheyeche
He has eaten pineapple
[7/20, 12:35 PM] patient advocate 1: স্যার প্রচন্ড ব্যাথা করতেছে।
Sir it's paining too much
[7/20, 12:39 PM] patient advocate 1: স্যার uni এখন বসে ও থাকতে parche na সুয়েও থাকতে parche na
Sir he can't sit and can't lie in the bed for pain
[7/20, 12:39 PM] patient advocate 1: স্যার প্রচন্ড ব্যাথা করতেছে।
Sir it's too much paining
[7/20, 12:46 PM] PaJR PHR Moderator: Goto kal 7PM er por kichu janan ni?
Paikhana kemon ache?
PHC daktar ke dekhiye ebong alochona kore
Tablet Buscopan (Hyoscine)10 mg dine teen bar aajker ek din
Tablet Paracetamol 640 mg dine char bar aajker ek din
You didn't tell us about his condition after yesterday 7pm, how was his stool? And after telling the local PHC TABLET BUSCOPAN (HYOSCINE) 10mg 3 times a day today and Paracetamol 640 mg 4 times a day
[7/20, 12:48 PM] patient advocate 1: পায়খানা ছিল নরমাল
Stool was normal
[7/20, 12:48 PM] patient advocate 1: মনে ছিল না মোবাইল নিয়ে যায়নি
তাই দিতে pareni
He didn't take his mobile that's why couldn't share
[7/20, 12:53 PM] PaJR PHR Moderator: Tarporer char ghontai ghontai temperature?
And the temperature in 4 hour?
[7/20, 12:54 PM] PaJR PHR Moderator: Aajker anarosh?
Today's pineapple
[7/20, 12:54 PM] patient advocate 1: তারপরে টেম্পারেচার ৯৬ পয়েন্ট ৩ ছিল
After that the temperature was 96.3°
[7/20, 12:58 PM] patient advocate 1: এখন 96.6
Now 96.6
[7/20, 1:27 PM] patient advocate 1: পেট ব্যাথা করতেছে khub onar
His stomach is paining a lot
[7/20, 1:28 PM] patient advocate 1: কথা বলতে parche na
He cannot say anything for pain
[7/20, 1:29 PM] patient advocate 1: বললে বেশী করে ব্যাথা করতেছে
Pain is increasing while talking
[7/20, 1:33 PM] patient advocate 1: বললে বেশী করে ব্যাথা করতেছে
Pain is increasing while talking
[7/20, 1:42 PM] patient advocate 1: জোরে নিঃশ্বাস নিলে ও পেট ব্যাথা করে
Pain is increasing while deep breathing
[7/20, 3:21 PM] patient advocate 1: ওষুধটা পাওয়া যায়নি স্যার
The medicine was not found here sir
[7/20, 3:22 PM] patient advocate 1: আমি তো বাড়ি চলে আসছি।
এখানে কোথাও পাইলাম না।
I've returned home
Nowhere found the medicine
[7/20, 4:13 PM] PaJR PHR Moderator: Ota to khub hi common oshudh!
Tablet Paracetamol 650 mg ta 6 ghonta baade baade dite paren. Apnar local PHC'r daktar ke oti oboshyoi dekhate bolben
That medicine is too common, take the tablet paracetamol 650 mg in every 6 hours. Ask your patient to show a local PHC.
[7/20, 4:24 PM] patient advocate 1: পি পি
PP
[7/20, 4:26 PM] patient advocate 1: হাই সি মার্কস ওষুধ টা কি খাওয়া যাবে
Can High C marks named medicine be eaten?
[7/20, 4:35 PM] PaJR PHR Moderator: Hain
Yes
[7/20, 4:35 PM] patient advocate 1: এটা কয়টা khabe দিনে? খাওয়ার আগে না পরে
How many dose to take a day? Before eating or after eating?
[7/20, 4:39 PM] PaJR PHR Moderator: Khub beshi byatha hole shudhu jeebher tolai rakhbte bolben
If there is too much pain just tell him to put it under the tongue
[7/20, 4:39 PM] PaJR PHR Moderator: Shudhu ekbar byatha hole
Just one time while pain
[7/20, 7:58 PM] patient advocate 1: এখন আর ব্যাথাটা নেই।
হালকা আছে আগের মত না।
Now there is no pain, slightly but not like before
[7/20, 8:04 PM] patient advocate 1: স্যার বলছিলাম এই ওষুধটা কালকেও khabe?
Sir will he eat this medicine tomorrow?
[7/20, 8:06 PM] PaJR PHR Moderator: Na
Shudhu byatha hole
No, only while pain
[7/20, 8:07 PM] patient advocate 1: ঠিক আছে স্যার
Ok sir
[7/22, 6:54 PM] PaJR PHR Moderator: @PaJR Coordinator This case report EHR is totally up-to-date now demonstrating pre hospital PaJR buy in and build up of the initial case story followed by hospitalization 2000 kms away and all the asynchronous conversations during admission, followed by discharge summary and final discharge diagnosis followed by the post discharge persistent clinical encounter in regular patient driven clinical problem solving and palliation 👇
Thanks to author @Pajr_Member 👏👏
[7/24, 4:55 AM] patient advocate: স্যার patient er পেট প্রচুর ব্যাথা করতেছে।
Sir my patient is having too much abdominal pain
[7/24, 7:57 AM] PaJR PHR Moderator: Apnar patient Tablet Hyoscimax jeebher tolai niyechilen ?
Had he taken Hyoscimax under is tongue
[7/24, 7:59 AM] patient advocate: হ্যাঁ niechilen।
ভোর পাস্টার সময় niechilen।
নেওয়ার পরে কিছুক্ষণ ভালো chilo তারপর আবার ব্যাথা হচ্ছে।
Yes he took it around 5 am, after taking the medicine he felt better, but then the pain again started
[7/24, 7:59 AM] patient advocate: একটা ছবি পাঠিয়ে দিচ্ছি, ওইখানেই ব্যাথা করে ছবিটা dekhun স্যার।
Sharing and pointing a picture of that body part where he is having pain, please see
[7/24, 8:00 AM] patient advocate: মার্ক করা জায়গাটার ভিতরটা তে ব্যথা করতেছে
The pointed area is paining
[7/24, 8:30 AM] patient advocate: স্যার পেটটা তো প্রচুর ব্যাথা করতেছে।
Sir he is having too much pain
[7/24, 8:31 AM] patient advocate: স্যার ওষুধটি আর একটা khabe ।
পাঁচটার সময় kheyechilo সকালবেলা।
এখন আরেকটা খাওয়া যাবে ?
[7/24, 8:36 AM] PaJR PHR Moderator: Hain
Ae chara Tablet, apnar patient, Paracetamol 650 mg proti 6 ghonta por por khete paren
Aer aage Hyoscimax khawar por byatha ta kotokkhon komechilo?
[7/24, 8:41 AM] +91 78720 53832: প্যারাসিটামল ৬৫০ খাচ্ছি তো ছয় ঘন্টা পর পর।
এর আগের দিন তো খাওয়ার পরে আর ব্যথা হয়নি।
খাওয়ার একঘন্টা পরই ব্যাথা গিয়েছিল।
কিন্তু আজকে যাচ্ছে না
[7/24, 8:52 AM] PaJR PHR Moderator: Ekbaar local PHC daktar ke oti oboshyoi dekhiye alochona kore neben
[7/25, 9:03 PM] +91 78720 53832: স্যার বলছে আজকে আমার শরীরটা অনেক খারাপ লাগতেছে কেন।
কিছু খাইতে মন চাইতেছে না শরীরটা কি রকম জানি ছটফট করতেছে।
[7/25, 9:07 PM] PaJR PHR Moderator: Goto kal patient er byathar sombondhe arektu janaben.
Kotokkhon chilo? Ki bhabe komlo?
[7/25, 9:08 PM] PA: গতকালকে আর একটা বরি খাওয়ার পরে ব্যথাটা নেই আর।
আজ পর্যন্ত আর ব্যথার নেই।
[7/25, 9:09 PM] PaJR PHR Moderator: Borir side effect er jonye aajke unar aei dhoroner koshto hocche
[7/25, 9:11 PM] PA: স্যার বলছিলাম এখন কিন্তু আগের মতো খাইতে ইচ্ছে করে না।
হাসপাতাল থেকে আসার পরে কয়েকদিন ভালোই খেতে ইচ্ছে করছিল।
এখন আবার খেতে ইচ্ছে দিন দিন কমে যাচ্ছে।
[7/26, 8:12 AM] PaJR PHR Moderator: Unar recent jei diarrhoea ta hoyechilo tar jonye
Aer aageo ki jokhon khawar icche kormechilo, tar aage diarrhoea hoyechilo?
Aer aage aei rokom khawar icche kobe ebong koto bar apnar patient er kormechilo? Date diye janate parle bhalo hoto
[7/26, 8:14 AM] PA: জুন মাসের ১০ তারিখ থেকে শুরু হয়েছিল।
খেতে ইচ্ছে করছিল না।
ঠিক ঐ রকমই আবার হচ্ছে।
[7/26, 8:55 AM] PaJR PHR Moderator: Aer aage kokhono aemon hoyechilo?
[7/26, 9:01 AM] PA: এর আগে এরকম একটা হয়নি।
এমনিতে এর আগে আমি খাওয়া-দাওয়া করছিলাম সকাল রাত্রে।
সকালবেলা খাওয়া দাওয়া করে কাজে গিয়েছিলাম দুপুর বেলা খাওয়া-দাওয়া করিনি একদম রাত্রে করি।
[7/26, 9:12 AM] PaJR PHR Moderator: Khawa dawar aei timing ki aer modhye change hoyeche?
[7/26, 9:19 AM] PA: চেঞ্জ হয়নি তো? হাসপাতালে যেই টাইম ছিল ওই টাইমে আছে
[7/26, 9:26 AM] PaJR PHR Moderator: Mane chotobelar theke aekhon obdhi patient er khawar timing guno shudhu matro sokal ebong raate?
Ekhane aeki time a khawar aage unar plate er chobi ta roj share korte parle arektu jana jeto
[7/26, 9:28 AM] PA: ছোটবেলা থেকে না মোটামুটি চার-পাঁচ বছর ধরে।
যবে থেকে কাজ করতে শুরু করেছি,
অন্যের বাড়িতে লেবারি তবে থেকে।
এর মধ্যে মাঝে মাঝে খেতাম।
কিন্তু বেশিরভাগ ক্ষেত্রেই খেতাম না দুপুরবেলা।
[7/26, 9:46 AM] PaJR PHR Moderator: Anyer bari te ki laebaari korte hoi sheta sombondhe ektu bistarito janate parle bhalo hoto
Roj ki aeki onyer bari? Roj ki aeki dhoroner laebaari?
What works he does in the others home? If can be known it will be better
He works in other's home daily? Daily same kind of work?
[7/26, 9:47 AM] patient advocate: অন্যের বাড়িতে রাজমিস্ত্রির সাথে হেলপারি kore
He helps the meson in others home
[7/26, 9:47 AM] patient advocate: বাড়িতে যখন কাজ থাকে তখন korena
When he stays in house he doesn't do
[7/26, 9:49 AM] PaJR PHR Moderator: Ki help koren sheta bistarito janaben
[7/26, 9:50 AM] PaJR PHR Moderator: Barite ki kaaj thake?
Maashe kobar barir kaajer jonye bairer kaaj korte jete paren na?
What does he do in the house? In a month how many days he cannot go to work?
[7/26, 9:50 AM] patient advocate: মসলা নিয়ে যাওয়া,ইট নিয়ে যাওয়া মিস্ত্রীকে দেওয়া এসবই করি
He delivers the ingredients, pass the bricks to the mason etc
[7/26, 9:51 AM] PaJR PHR Moderator: 👆
[7/26, 9:52 AM] patient advocate: মাসে ১৫ থেকে ১৭ কাজ kore বাকি দিন বাড়িতে কাজ kore।
He works 15-17 days outside and rest days works in the house
[7/26, 9:57 AM] patient_advocate: এখন থেকে টোটো chalabe ।
From now he will drive TOTO
[7/26, 9:58 AM] PaJR PHR Moderator: Barite unar ki kaaj thake?
What does he do in the house?
[7/26, 9:58 AM] patient advocate: এই ধান চাষ করা তামাক চাষ করা পাট চাষ করা ইত্যাদি
Rice ,jute farming etc
[7/26, 9:59 AM] PaJR PHR Moderator: @Pajr_member thanks for updating the patient's EHR case report till 20/7/24
[7/26, 11:01 AM] PajR member: Updating it as soon as possible.
[20-04-2025 12:10] PPM 1: Patient er goponiyota rokkharte aeguno delete kora holo
Aemni patient er sompoorno information unar case report a ekhane royeche 👇
[20-04-2025 16:05] +964 750 136 1306: The patient's case report you've shared appears to detail a 28-year-old male diagnosed with *abdominal migraine* alongside a history of gallbladder removal (cholecystectomy). Below is a concise summary of key points and considerations:
---
### 1. *Abdominal Migraine Overview*
- Abdominal migraine is a rare condition, primarily seen in children but occasionally in adults.
- Symptoms include recurrent episodes of *moderate-to-severe abdominal pain*, nausea, vomiting, and lethargy, often with no headache.
- Triggers may include stress, dietary factors, or hormonal changes.
---
### 2. *Gallbladder Removal (Cholecystectomy)*
- The surgery (goponiyota delete kora) is typically performed for gallstones, inflammation, or biliary dysfunction.
- Post-cholecystectomy syndrome (PCS) can sometimes cause residual symptoms like indigestion, bloating, or pain, but it is unrelated to abdominal migraine.
---
### 3. *Possible Connections?*
- *Stress Trigger*: Surgery or recovery stress could theoretically exacerbate migraine conditions, including abdominal migraines.
- *GI Dysfunction*: Post-surgery digestive changes might indirectly affect gut-brain interactions (e.g., via the vagus nerve), potentially influencing migraine pathways.
- *Coincidental Conditions*: Abdominal migraine and gallbladder disease may coexist without a direct link.
---
### 4. *Case Report Highlights (Based on Link)*
- The patient had *1 month of headaches* and abdominal pain, suggesting overlapping neurological and gastrointestinal issues.
- Diagnostic workup likely ruled out other causes (e.g., infections, obstructions, or metabolic disorders).
- Management may involve *migraine prophylaxis* (e.g., amitriptyline, propranolol) and dietary modifications.
---
### 5. *Recommendations*
- *Neurology/Gastroenterology Collaboration*: Ensure both abdominal migraine and post-cholecystectomy symptoms are addressed.
- *Dietary Adjustments*: Avoid migraine triggers (e.g., caffeine, processed foods) and manage post-surgery digestion with low-fat, high-fiber meals.
- *Stress Management*: Cognitive behavioral therapy (CBT) or relaxation techniques may help reduce migraine frequency.
---
If you’re the patient or caregiver, consult a specialist to tailor treatment. If you’re a medical professional, further investigation into gut-brain axis mechanisms or referral to a migraine clinic may be warranted.
[20-04-2025 19:03] PA: স্যার আমি এই মাসের 30 তারিখ KIMS Hospital যেতে চাই।
এখন আমি সাইকেল চালিয়ে যেতে পারছি না।
সাইকেল চালালেও মাথা ব্যাথা করে।
[20-04-2025 19:04] PA: এমনিতে সারাক্ষণ মাথাটা ব্যাথা করে থাকি সাইকেল চালালে বেশি হয় দৌড়ালে ব্যাথা করে এখন।
[16-06-2025 19:22] PA: স্যার আমি পয়সার অভাব এ আগের date যেতে পারিনি।
এখন পনেরো দিন এর মধ্যে যেতে চাই ?
আমার মাথা ব্যাথা এখনও করে গাড়ীতে চড়লে।
আমি পেশায় Toto চালক।
সকাল থেকে দুপুর পর্যন্ত toto চালালে মাথা ব্যাথা করে না
কিন্তু দুপুরের পর থেকে সন্ধ্যা পর্যন্ত toto চালালে মাথা ব্যাথা করে।
তাই যেতে চাইতে ছি।
যাওয়া কি যাবে এখন ?
[16-06-2025 19:26] PA: Toto না চালালে আমার সংসার চলেনা।
আমার পরিবারের কামাই করার লোক আমি একমাত্র।
আমি ছাড়া আর কেউ নেই।
পরবারের সদর্শ আমি সহ ছয় জন।
আমার বাবা, মা, স্ত্রী, আর আমার দুই মেয়ে।
বাবা মায়ের বয়স হয়েগেছে তারা কিছু করতে পারে না।
[16-06-2025 21:29] PA: স্যার আমি কি যাব
[17-06-2025 08:40] PPM 1: Added @~Tamoghna for the presumed abdominal migraine component
[18-06-2025 20:17] PA: Er maneta ami bujhte parlam na sir
এর আগে যে থ্যালাসেমিয়া পেসেন্ট তার ছবি কাগজ পাঠিয়েছিলেন সেই থ্যালাসেমিয়ার পেসেন্ট টা মারা গেছে এর ছোট ভাই ছিল এরা চার ভাই ছিল দুই ভাই থ্যালাসেমিয়া মারা গেছে আর দুই ভাই আছে হিরো মাঝে মাঝে সমস্যা হয় তো সেজন্য ওখানে যাইতে চায় যদি বলেন তাহলে নিয়ে যেতে পারি আমার কাকার ছেলে হয়
আমি এতদিন পয়সার অভাবে যাইতে পারিনি স্যার এইজন্য আমি দুঃখিত।
এখন যাইতে চাইতেছি মোটামুটি সপ্তাহিকের মধ্যে কি বলেন
[25-06-2025 20:34] PPM 1: Unader boyesh koto?
Niye aaste paren.
[25-06-2025 20:36] PA: 21 bochhor
[25-06-2025 20:38] PA: Kobe jabo
[25-06-2025 22:08] PPM 1: Jokhon parben
[28-06-2025 21.42] PA: স্যার আমার এখন সমস্যা আছে শুধু মাথা ব্যাথা
রোদ উঠলি মাথাটা ব্যাথা করে
আর টোটো চালাতে পারি না
টোটো চালালে মাথাটা বেশি করে ব্যাথা করে।
রাতে একটু ঘুম কম হয় আর খাওয়ার কোন রুচি নেই।
[02-07-2025 23:29] PA: স্যার আমি কোন স্টেশনে নামবো ?
[03-07-2025 06:42] PA: স্যার আমি থ্যালাসেমিয়া পেসেন্ট টা কে নিয়ে যাচ্ছি
[03-07-2025 14:39] PA: স্যার আমরা ট্রেনে উঠলাম
[03-07-2025 17:31] PA: স্যার ট্রেন এ আমার মাথা টা খুবই বেশি ব্যাথা করছে।
প্রচুর পরিমানে মাথা ব্যাথা করছে।
[05-07-2025 08:28] PA: স্যার আমি চারলাপল্লি station এ নামলাম
Nalgonda station এ ট্রেন দাঁড়ায়নি।
[05-07-2025 08:28] PA: এখান থেকে খাওয়াদাওয়া করে হাসপাতালে যাবো ।
[05-07-2025 12:16] PA: স্যার আমরা হাসপাতালের বাইরে
[05-07-2025 13:07] PPM 1: 2:30PM ICU te dekha korben
[05-07-2025 13:36] PA: স্যার আমার সঙ্গে থ্যালাসেমিয়ার পেশেন্ট টা আছে
[05-07-2025 13:38] PA: আমরা রেজিস্ট্রেশন করেছি দুইজনেই
[05-07-2025 14:26] PA: স্যার আমরা ICU এর সামনে
[05-07-2025 16.55] PPM 1: Reviewed again with a synchronous face to face encounter just now and admitted today as he's from long distance:
29M visiting after a year after taking a loan of 20,000 from his friends because he's still distressed by his chronic headache which is disrupting his work!
In 2022 he used to work as a mason but left his job once a rod fell on his head and he has been having intermittent headache ever since then every week.
He changed his job buying a toto/auto again taking loan and is yet to clear the last two installments and meanwhile because of his headache and distress he is unable to even drive his auto on the road particularly as he notices that the uneven jerking on the roads often leads to jarring headache!
@PPM6 what would you suggest as a jeevan yapan measure here?
[05-07-2025 17:12] PA: @PPM5 just retook the history:
[05/07, 17:06]: 30/male
• Chief Complaint: Headache for 3 years
History of Present Illness:
The patient was apparently asymptomatic until 3 years ago, when they developed a headache of insidious onset and gradually progressive course. The headache has been intermittent, but has shown aggravation over the past 3 months.
The headache is:
• Relieved with medications
• Associated with photophobia, phonophobia, conjunctival congestion
• Not associated with nausea, vomiting, lacrimation, or nasal congestion
Relevant Events:
• History of fall from a height with a heavy object falling on the head 5 years back
• Headache began 2 years post-trauma
• Increased severity in the past 3 months
• One episode of hematemesis 5 days ago( 2 times , scanty amount )but no recurrence
. H/O loss of appetite since 3 months
. patient stopped going to work due to headache since 3 months
. H/O passing hard stools since 3 months
⸻
History of Present Illness (Negative Symptoms):
• No history of dizziness, loss of consciousness, ear discharge, or seizure-like activity
• No chest pain, palpitations, dyspnea, orthopnea, pedal edema
• No abdominal pain, dysuria, fever, cough, or cold
⸻
History of Past Illness:
• No known comorbidities
• Medications:
• T. Amitriptyline 25 mg PO/HS
• T.Paracetamol 650 mg PO SOS
• History of abdominal migraine since 1 year
•history of? epilepsy
[05/07, 17:07]: Sir what investigations should i send
[05-07-2025 17:14] PPM 1: @PPM5 get an Ophthal opinion for fundoscopy to rule out papilledema
Hemogram
Psy opinion
[05-07-2025 17.33] PPM 5: Okay sir, why psychiatry opinion sir.
[05-07-2025 19:31] PPM 1: Traumatic brain injury, diffuse axonal injury as in this patient can lead to a complex interplay of physical, cognitive, and psychological symptoms, including headaches, mood disorders as meticulously reported previously by one of our PGs along with the psychiatry PGs here👇
[06-07-2025 07:35] PA: স্যার এই ড্রপ টা আমার চোখে দিতে বলল ৫ মিনিট পর পর এক ফোটা করে।
এটা কি দিব
[06-07-2025 10:14] PA: স্যার এই ড্রপ টা দেওয়ার পর থেকে চোখ দিয়ে কিছুই দেখা যাচ্ছে না ঝাপসা দেখা যাচ্ছে ফোনের লেখাগুলো ধরতে পারছি না
[06-07-2025 15:25] PPM 1: Pore thik hoye jabe
[06-07-2025 15:36] PA: স্যার এই গ্রুপটা দিনে কবার দিব
[06-07-2025 19:16] PPM 1: @PPM5 please share the Ophthal notes. The patient wants to know how many times does he need to take the pupillary dilator eye drops before they examine him.
[06-07-2025 21:32] PPM 5: yes sir
[06-07-2025 21:43] PPM 1: What time was the above Ophthal examination done?
[06-07-2025 21:56] PPM 5: Today morning at 8am sir
[06-07-2025 22:05] PPM 1: Hope they advised him to not apply it again after that?
[07-07-2025 12:24] PPM 1: @PA dujone ekkhuni OPD te chole ashun taratari. Aro history newar chilo
[07-07-2025 13:05] PPM 1: @PPM5 @PPM7 he's complaining of a weight loss of 10 kgs over last 3 months
[07-07-2025 14:42] PPM 5: স্যার আমরা তো ICU গিয়েছিলাম ওখানে আপনি নাই
ওখানে আমাদেরকে থাকতে দিল না
আমরা ওয়ার্ডে চলে আসলাম আবার
[07-07-2025 14:45] PPM 1: Ami aashchi.
[07-07-2025 15:37] PA: স্যার ওনার বাবা ফোন করে বলল থ্যালাসেমিয়া টেস্ট টা করে দেখো ।
মনের ভয় তাই বলছে টেস্ট টা করিয়ে দেখতাম কতটুকু আছে
[07-07-2025 15:39] PPM 1: Thik achhe
[07-07-2025 15:39] PA: Ok স্যার
[07-07-2025 15:39] PPM 1: @PPM5 @PPM8 please share his psy notes
[07-07-2025 15:49] PPM 1: Thanks.
Where's their last page?
[07-07-2025 16:47] PPM 1: Alright. Let's start Mirtazepine from today
[07-07-2025 16:50] PPM 1: 👆@PPM9 @PPM10 @Researcher @PPM11 check out this hand written over testing and treatment narrative which possibly reflects the plight of a large majority of chronic illness sufferers in India who spend their savings unnecessarily in over testing and treatment and quickly go down the poverty line
[08-07-2025 08:54] PA: স্যার আজকে রাত্রে ঘুম ভালো হয়েছিল
[08-07-2025 09:02] PA: মাথা ব্যথা কমতেছে না।
হালকা করে ব্যাথা করেই আছে।
[08-07-2025 10:03] PA: স্যার আপনি কি হাসপাতালে এসেছেন আসলে আমি দেখা করতাম
[08-07-2025 10:03] PPM 1: OPD te
[08-07-2025 10:28] PA: স্যার আমরা ওপিডিতে আছি ।
৭৮ নাম্বার রুমের সামনে
[08-07-2025 10:47] PPM 1: Amio anek khon dhore ekhane kintu apnader dekhlam na.
[09-07-2025 08:35] PA: স্যার আমার মাথা ব্যথাটা কমতেছে না তো। সারাদিন মাথাব্যথা করে দিতে হালকা করে। এখানে এখন তো রুদ্রে যাওয়া হয়নি কোন সেরকম কাজও করা হয়নি। এমনিতে যেহেতু সারাদিন ব্যাথা করে কাজ করলে বা রোদ্রে গেলে মনে হয় ব্যাথা করবেই বেশি করে।
[09-07-2025 08:39] PA: স্যার তোমার সঙ্গে দেখা করা কখন যাবে? কোথায়
[09-07-2025 10:19] PPM 1: OPD te
[09-07-2025 10:23] PPM 1: @PPM5 @Meta AI @PPM3 @CR @PPM2 in this patient who appears to have failed amitriptyline prophylaxis for his migraine (to which he did respond for initial 6 months during his last visit a year ago), would it be a good idea to switch to propranolol prophylaxis, given that in this admission a lot more depression issues have been unearthed and he's already been started on mirtazepine? Would there be any potential drug interactions to be wary of?
[09-07-2025 10:23] Meta AI: Given the patient's history of responding to amitriptyline initially but failing prophylaxis this time, and considering the depression issues that have surfaced, switching to propranolol might be a viable option. However, potential interactions between propranolol and mirtazepine should be monitored.
Propranolol is often used for migraine prophylaxis and can be effective, but its interaction with mirtazepine isn't typically significant in terms of pharmacokinetics. Nonetheless, both drugs can affect blood pressure, and propranolol's beta-blocking effects might mask certain signs of hypoglycemia if relevant.
More importantly, given the patient's depression issues and the initiation of mirtazepine, monitoring for any changes in mood or anxiety levels when introducing propranolol would be prudent. Propranolol can sometimes be used off-label for performance anxiety or certain types of tremors but is generally not known for exacerbating depression directly. However, individual responses can vary.
The key consideration would be closely monitoring the patient's response to propranolol, both in terms of migraine prophylaxis efficacy and any potential impact on his depression or interaction with mirtazepine. Regular follow-ups would help in assessing the effectiveness and safety of this switch.[09-07-2025 10:25] PPM 2: Data suggests so, yes a switch can be attempted.
[09-07-2025 10:27] PA: স্যার আমরা তো ওপিডি সামনে
[09-07-2025 10:33] +91 78720 53832: স্যার আমরা 78 রুম নাম্বার এখানে বসে আছি
[09-07-2025 10:33] Rakesh Biswas Sir: Aashchi
[09-07-2025 12:10] +964 750 136 1306: Based on the clinical scenario, switching to propranolol for migraine prophylaxis is *a reasonable option, but requires careful consideration and monitoring* due to the patient's depression and concurrent mirtazapine use.
Here's the breakdown:
1. *Propranolol as Migraine Prophylaxis:*
* Propranolol is a *first-line agent* for migraine prevention (Level A evidence from AAN guidelines). It's effective in many patients.
* Its mechanism (beta-blockade) is different from amitriptyline (TCA), making it a logical alternative after amitriptyline failure.
2. *Concerns Regarding Depression:*
* *Propranolol Side Effect Profile:* Beta-blockers like propranolol are *notorious for potential neuropsychiatric side effects*, including:
* *Depression:* Can cause depressive symptoms or worsen existing depression (though evidence for causing major depression is debated, exacerbating it is a significant concern).
* *Fatigue/Lethargy:* Very common, which can mimic or worsen depressive fatigue.
* *Sleep Disturbances:* Vivid dreams/nightmares.
* *Newly Uncovered/Managed Depression:* Starting a drug with this side effect profile in a patient with recently identified and active depression being treated with mirtazapine is *a major point of caution*. The risk of worsening depression or reducing the effectiveness of mirtazapine is real.
3. *Mirtazapine Interaction Considerations:*
* *Pharmacodynamic Interactions (Main Concern):*
* *Additive Sedation:* Both mirtazapine (especially at lower doses like 15mg) and propranolol can cause significant drowsiness and sedation. This combination is *very likely to cause pronounced fatigue, drowsiness, and impaired cognitive/motor function*, especially initially.
* *Additive Hypotension/Bradycardia:* Propranolol lowers blood pressure and heart rate. Mirtazapine has minimal direct cardiovascular effects at therapeutic doses but can rarely cause orthostatic hypotension. The combined effect could potentially lead to symptomatic hypotension or bradycardia, especially in susceptible individuals or with higher doses. *Careful monitoring of BP and HR is essential.*
* *Potential Impact on Depression:* As above, propranolol could counteract some of the antidepressant effects of mirtazapine by inducing fatigue or depressive symptoms.
* *Pharmacokinetic Interactions (Less Concern):*
* Propranolol is metabolized primarily by CYP1A2 and CYP2D6.
* Mirtazapine is a weak inhibitor of CYP2D6 and CYP3A4, but clinically significant inhibition leading to markedly increased propranolol levels is *unlikely*. Mirtazapine is metabolized mainly by CYP2D6, CYP1A2, and CYP3A4. Propranolol does not significantly inhibit or induce these enzymes.
* *No major pharmacokinetic interaction is expected.* The primary concerns are additive effects on sedation, cardiovascular parameters, and mood.
4. *Alternatives to Consider:*
* *Anticonvulsants:* Topiramate (monitor for cognitive side effects, weight loss, potential mood changes - caution in depression) or Valproate (avoid in women of childbearing potential, weight gain, tremor, requires monitoring).
* *CGRP Monoclonal Antibodies:* Erenumab, Fremanezumab, Galcanezumab (highly effective, minimal drug interactions, generally favorable side effect profile - ideal if accessible/cost not prohibitive).
* *Candesartan or Lisinopril:* ARBs/ACEIs have some evidence for migraine prevention and generally favorable neuropsychiatric profiles.
* *Botulinum Toxin A (Botox):* Approved for chronic migraine, good option if criteria are met, no systemic interactions.
*Recommendation & Management Plan:*
1. *Switching to Propranolol is Acceptable, BUT:*
* *Prioritize Depression Stability:* Ensure the depression is adequately managed with mirtazapine before adding propranolol, if possible. Document baseline mood clearly.
* *Start Low, Go Slow:* Initiate propranolol at a very low dose (e.g., 10mg twice daily or 20mg once daily). Titrate upwards slowly (e.g., weekly increases of 10-20mg/day) based on migraine response and tolerability. Target dose is typically 40-160mg/day in divided doses.
* *Vigilant Monitoring:*
* *Depression:* Closely monitor mood, energy, motivation, suicidal ideation (PHQ-9 tracking is useful). Explicitly ask about worsening depressive symptoms. *Worsening depression is a strong reason to discontinue propranolol.*
* *Sedation:* Warn the patient about significant drowsiness, especially in the first 1-2 weeks. Advise caution with driving/operating machinery until effects are known. Taking propranolol at bedtime may help mitigate daytime sedation.
* *Vital Signs:* Monitor blood pressure and heart rate regularly, especially during dose titration. Watch for symptomatic hypotension or bradycardia.
* *Migraine Response:* Track headache frequency, severity, and duration.
* *Patient Education:* Thoroughly discuss potential side effects (fatigue, dizziness, depression worsening, sleep issues) and the importance of reporting them promptly.
2. *Strongly Consider Alternatives (Especially CGRP mAbs):* Given the significant concern about depression exacerbation and the high likelihood of troublesome sedation with the mirtazapine combination, *exploring non-beta-blocker alternatives like a CGRP monoclonal antibody is often the preferred strategy in this specific clinical scenario.* If CGRP mAbs are not feasible, candesartan or topiramate (with close mood monitoring) might be better initial choices than propranolol.
*In summary:*
* Propranolol is a valid migraine prophylactic option after amitriptyline failure.
* *However, its potential to worsen depression and cause significant additive sedation with mirtazapine makes it a higher-risk choice in this patient.*
* If chosen, *extreme caution with dosing and vigilant monitoring for depression worsening and sedation are absolutely mandatory.*
* *Strongly consider alternatives like CGRP monoclonal antibodies, candesartan, or topiramate first,* as they avoid the specific neuropsychiatric risks associated with propranolol in a depressed patient on mirtazapine. The decision should weigh the severity of migraines, the stability of the depression, patient preference, and access to alternatives like CGRP mAbs.
[09-07-2025 12:19] PPM 1: Nice to have the caution on propranolol but the suggested alternatives like cgrp antibodies appears far-fetched?
[09-07-2025 12:23] PPM 3: Based on your concerns about propranolol's risks and the feasibility of CGRP monoclonal antibodies (mAbs), here's a balanced analysis of alternatives, emphasizing practical options and clarifying CGRP accessibility:
---
### ⚠ *Key Concerns with Propranolol in This Case*
1. *Depression exacerbation risk*:
- Propranolol is associated with neuropsychiatric side effects (depression, fatigue, nightmares) in 1–12% of users.
- With this patient's newly uncovered depression, this risk is significant and may counteract mirtazapine's benefits.
2. *Pharmacodynamic interactions with mirtazapine*:
- *Additive sedation*: Both drugs cause drowsiness, increasing fall/cognitive impairment risk.
- *Hypotension/bradycardia*: Propranolol lowers blood pressure/heart rate; mirtazapine rarely causes orthostatic hypotension.
- Note: No major pharmacokinetic interactions exist, but functional overlaps are concerning.
---
### 🔄 *Practical, Non-"Far-Fetched" Alternatives to Propranolol*
While CGRP mAbs are ideal for refractory cases, these are accessible, evidence-backed options:
#### ✅ *First-Line Alternatives with Lower Depression Risk*
| *Option* | *Mechanism* | *Pros* | *Cons* | *Evidence* |
|--------------------|---------------------|------------------------------------------|------------------------------------------|-----------------------------------------|
| *Candesartan* | ARB (angiotensin blocker) | Minimal depression risk, weight-neutral | Weak efficacy; limited insurance coverage | 50% reduction in 20–30% of patients |
| *Topiramate* | Anticonvulsant | No cardiac/depression risks; aids weight loss | Cognitive side effects (25–30% of users); avoid in glaucoma/kidney stones | Level A evidence; comparable to propranolol |
| *Venlafaxine* | SNRI antidepressant | Addresses depression + migraine; no anticholinergic effects | Nausea, hypertension risk; slow titration needed | Comparable to amitriptyline for migraine |
#### ⚠ *Specialist-Dependent Options (If First-Line Fails)*
- *CGRP mAbs (e.g., erenumab, galcanezumab)*:
- *Why not "far-fetched"?*
- Now *first-line per 2024 guidelines* for patients failing 1–2 preventives.
- Covered by most insurers after prior authorization (≥3 failed preventives in the UK/US) .
- *Efficacy*: 50–75% reduction in migraine days in 40–60% of patients; onset in 1–4 weeks.
- *Safety*: Minimal interactions; no sedation/cardiac effects.
- *Botox (onabotulinumtoxinA)*:
- For *chronic migraine* (≥15 headache days/month).
- Administered quarterly; no systemic interactions.
---
### ⚖ *Balanced Recommendation*
1. *Avoid propranolol* unless depression is stable and no other options exist. If used:
- Start at 10–20 mg/day; monitor mood/PHQ-9, BP, and sedation weekly.
2. *Prioritize accessible alternatives*:
- *Depression-dominant*: Venlafaxine (start 37.5 mg/day).
- *Minimal side effects*: Candesartan (start 4–8 mg/day).
- *No cardiac issues*: Topiramate (start 25 mg/day).
3. *Initiate CGRP mAb referral now*:
- Process takes weeks; use while titrating other drugs. If eligible, they offer *superior tolerability and speed* vs. oral drugs.
4. *Non-pharmacological supports*:
- Cognitive behavioral therapy (CBT) for migraine + depression synergy.
- Trigger avoidance diaries to reduce preventive drug burden.
---### 💡 *Why CGRP mAbs Are Less "Far-Fetched" Than Perceived*
- *Access*: Most major insurers cover them after documented failures of 3 generics (e.g., amitriptyline, topiramate, propranolol) .
- *Cost programs*: Manufacturers offer copay cards (e.g., Aimovig™: $0–$25/month) .
- *Administration*: Monthly self-injections (similar to insulin pens) .
If cost/access remains a barrier, *candesartan + CBT* is the safest interim step. Reassess in 3 months for CGRP eligibility.
[09-07-2025 14:50] PA: স্যার আমার মাথা ব্যাথা করছে আগের চেয়ে অনেক বেশী যা সর্জ করা আমার খুব কষ্ট হচ্ছে।
[09-07-2025 18:48] PA: স্যার আমার মাথা ব্যাথা করতেছে প্রচুর ।
প্যারাসিটামল খেয়েছি তবুও ব্যাথা করতেছে ।
[09-07-2025 19:36] PA: স্যার আমার মাথা ব্যাথা কমছে না তো ।
[09-07-2025 19:54] PA: স্যার ব্যাথা জন্য কষ্ট হচ্ছে খুব ।
শুয়ে থাকতে পারছি না বসে থাকতে পারছি না দাঁড়িয়ে থাকতে হচ্ছে ।
[09-07-2025 22:11] PPM 1: @PPM5 @PPM12 please ask the PG on duty to check and share here as to if there are any clinical red flags in his headache asap
[09-07-2025 22:17] PPM12: Sir I checked patient he is fine now I gave pcm 650mg tablet
[10-07-2025 10:11] PA: স্যার আমার মাথা ব্যাথা টা কমতেছে না তো ।
এখানে ঘরে যদি মাথা ব্যথা করে বাইরে গেলে তার বেশি করবে ।
[10-07-2025 12:43] PPM 1: Ekhane psychiatry OPD te aajke arekbar dekhiye nin
[10-07-2025 12:43] PPM 1: Get him reviewed again today in psychiatry
[10-07-2025 14:11] PA: স্যার তখন মনে হয় ডাকছিলেন কিন্তু আমার মোবাইল ছিল না আমার কাছে চার্জে দেওয়া ছিল এখন দেখা করা যাবে স্যার
[10-07-2025 14:12] PA: যদি যায় কোথায় যাবো একটু বললে ভাল হত
[10-07-2025 14:15] PA: স্যার আজকে দেখা করা যাবে
[10-07-2025 14:20] PPM 1: ICU
[10-07-2025 14:22] PA: স্যার আমরা আসছি
[10-07-2025 18:06] PA: এক জন জিজ্ঞেস করল যে হাসপাতাল এ আসলে কি নিয়ে চিকিৎসা হয়
[10-07-2025 18:06] PA: স্যার এই হাসপাতালে কিসের চিকিৎসা হয়।
[10-07-2025 19:58] PPM 1: Shob kichur
[10-07-2025 19:59] PPM 1: @PPM5 please pm me the discharge summary
[10-07-2025 20:53] PPM 5: okay sir
[11-07-2025 08:47] PPM 1: EMR summary for the case report update:
Gender: 30 Years/Male
Admission Date: 05/07/2025 04:07 PM
Diagnosis
POST TRAUMATIC HEADACHE (RESOLVING)
MODERATE DEPRESSIVE DISORDER
ADJUSTMENT DISORDER
Case History and Clinical Findings
CHIEF COMPLAINTS
C/O HEADACHE SINCE 3 YEARS
HOPI :
PATIENT WAS APPARENTLY ASYMPTOMATIC 3 YEARS AGO ,THEN HE DEVELOPED
HEADACHE , INSIDIOUS ONSET, GRADUALLY PROGRESSIVE, INTERMITTENT, AGGREVATED
SINCE 3 MONTHS, RELIEVED ON MEDICATION ASSOCIATED WITH PHOTOPHOBIA +,
PHONOPHOBIEA , CONJUCTVAL CONGESTION.
NO H/O NAUSEA , VOMITING, LACRIMATION, NASAL CONGESTION
H/O FALL OF UNKNOWN HEAVY OBJECT ON HEAD 5 YEARS BACK, 2 YEARS FOLLOWING
WHICH PATIENT DEVELOPED HEADACHE
H/O LOSS OF APPETITE SINCE 3 MONTHS
H/O OF PASSING HARD STOOLS SINCE 3 MONTHS
NO H/O GIDDINESS, LOC, EAR BLEED, SEIZURE LIKE ACTIVITY
NO H/O CHEST PAIN, PALPITATIONS, SOB, PEDAL EDEMA, ORTHOPNOEA
NO H/O PAIN ABDOMEN, BURNING MICTURITION, HEMATURIA
NO H/O FEVER, COUGH O HEMETEMESIS 5 DAYS AGO [TWO TIMES IN A DAY] AND NO EPISODE LATER.
H/O STOPPAGE OF ROUTINE DAILY WORK
NO KNOWN COMORBIDITIES
DRUG HISTORY : USING TAB. AMITRYPTALINE 25 MG PO/OD /HS
TAB. DOL 650 MG PO/SOS
K/C/O ABDOMINAL MIGRANE SINCE 1 YEAR RESOLVED NOW
N/K/C/O DM, TB,EPILEPSY ,THYROID ,CVA ,CAD
PERSONAL HISTORY: MARRIED, MIXED DIET, REGULAR BOWEL AND BLADDER
MOVEMENTS , NO KNOWN ALLERGIES
ADDICTIONS - ALCOHOL [ CONSUMES OCCASIONALLY]
TOBACCO CHEWING IN THE FORM OF KYNI
FAMILY HISTORY - NOT SIGNIFICANT
GENERAL EXAMINATION
NO PALLOR , NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, PEDAL EDEMA,
MALNUTRITION
VITALS:- TEMP: 98.0 F, BP: 110/80MMHG, RR: 16 CPM, PR: 86 BPM, SPO2: 99% AT RA,
SYSTEMIC EXAMINATION
CVS , RS, PER ABDOMEN - NORMAL
CNS- NO FOCAL NEUROLOGICAL DEFICITS
PATIENT WAS SENT TO OPHTHALMOLOGY REFERAL I/V/O PAPILLEDEMA
IMPRESSION : NORMAL FUNDUS STUDY
: NO RAISED ICT FEATURES
PATIENT WAS REFFERED TO PSYCHIATRY ON 7/7/25
IMPRESSION: MODERATE DEPRESSIVE DISORDER
ADJUSTMENT DISORDER
TREATMENT : PATIENT IS COUNSELLED AND PSYCHOEDUCATED
TAB. MIRTAZAPINE 7.5MG X-X-1 X 4 DAYS
X-X-2 X 10 DAYS
SLEEP HYGEINE TECHNIQUE explained
HEMOGRAM ON 05/07/25: HAEMOGLOBIN 10.2 gm/dl, TOTAL COUNT 6,300 cells/cumm ,
NEUTROPHILS 53%, LYMPHOCYTES 40 % , EOSINOPHILS 02 % , MONOCYTES 05 %,
BASOPHILS 00 % , PCV 31.5 vol % , M C V 60.1 fl , M C H 19.5 pg , M C H C 32.5 % , RDW-CV
15.6 % , RDW-SD 35.9 fl , RBC COUNT 5.24 millions/cumm , PLATELET COUNT 1.70 lakhs/cumm.
SMEAR: RBC Normocytic normochromic, WBC normal, PLATELETS inadeqaute. NO
HEMOPARASITES, IMPRESSION Normocytic normochromic anemia
Treatment Given (Enter only Generic Name)
TAB. AMITRYPTILLINE 25 MG PO/HS
TAB.MIRTAZAPINE 7.5MG PO/HS X-X-1 FOR 4 DAYS
TAB.NAPROXEN 250MG PO/SOS
Advice at Discharge
TAB . AMITRYPTILLINE 25 MG PO/HS ( X-X-1) X20DAYS
TAB.MIRTAZAPINE 7.5MG PO/HS X-X-2TABLETS FOR 10 DAYS
TAB.NAPROXEN 250MG PO/SOS
Follow Up
REVIEW TO GENERAL MEDICINE OP AFTER 15 DAYS OR SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:
08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed
and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been
explained to me in my own language SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date
Date:11/7/25
Ward: MMW
Unit:5
@PPM7 please share your patient's EMR summary in the above text format
[11-07-2025 08:48] PPM 7: Okay sir
[11-07-2025 09:07] PA: স্যার আপনার সঙ্গে দেখা করতাম ।
কখন কোথায় করবো স্যার
[11-07-2025 09:56] PA: Dekha
[11-07-2025 10:02] PPM 1: OPD
[11-07-2025 16:07] PA: স্যার এখন আমাদের ছুটি দিলো এখান থেকে station গিয়ে থাকাটা অসুবিধা হবে।
গিয়ে ওখানে রাত থাকতে হবে ।
কারণ আজ কি যায়ার কোনো ট্রেন নেই ।
তাই আজকে রাত্রে এখানে থেকে কালকে সকাল বেলায় আমরা চলে যেতাম ।
[11-07-2025 16:08] PA: এখন আমরা ওষুধও নেইনি ।
ওষুধ নিতে আরো দেরি হবে ।
তাছাড়া আজকের এখানে থেকে কালকে সকাল বেলা চলে যেতাম আমরা ।
[11-07-2025 16:10] PA: কোন ওষুধগুলো নেব ।
[11-07-2025 16.16] PA: স্যার
[11-07-2025 16:52] PPM 1: Tablet Mirtazepine 15 mg before dinner
[11-07-2025 16:53] PA: স্যার তাহলে আমরা হাসপাতালেই থেকে গেলাম।
কাল সকাল বেলা যাব স্যার একটু হাসপাতালে বলে দিয়েন
[11-07-2025 16:55] PPM 1: @PPM5 please inform the admin to allow them to stay the night
[11-07-2025 17:00] PA: অনেক অনেক ধন্যবাদ স্যার
[12-07-2025 09:28] PA: স্যার আমরা যাচ্ছি স্টেশনে
[12-07-2025 09:30] PA: হাসপাতাল থেকে বেরোলাম
[14-07-2025 20:07] PA: Sir এখানে trytomer 25 mg লেখা ছিল।
ওষুধগুলো আমার ভাইয়া নিয়েছিল।
বাড়িতে এসে দেখি ওগুলো নিয়েছে
ওগুলো কি খাবো না শুধু এটাই খাব
[14-07-2025 20:14] PPM 1: Aekhon shudhu Mirtazepine tai khan
[14-07-2025 20:18] PA: Ok sir
[14-07-2025 20:20] PA: Eta khabar pore khabo na aage khabo
[14-07-2025 20:25] PA: Kokhon khabo sir
[14-07-2025 20:25] PPM 1: Khabar aage raate
[17-07-2025 04:08] PA: স্যার কালকে সন্ধ্যার দিকে চোখে বালা পড়ছিল ।
আজকে তো একটা বছর ব্যাথা করতেছে লাল হয়েছে কি করা যায়
[17-07-2025 06:24] PA: স্যার কোন একটা ওষুধ থাকলে লিখে দেন না চোখটা খুব ব্যাথা করতেছে আমাদের এখানে আশেপাশে কোন সরকারি হাসপাতাল নেই এখান থেকে মোটামুটি দেড়শ কিলোমিটার দূরে আছে
ওষুধের দোকান আছে নামটা বললে একটু নিয়ে আসতাম
[17-07-2025 07:47] PPM 1: Local health center nei?
[17-07-2025 08:08] PA: না
[21-07-2025 19.55] PA: স্যার এটা কি মাথা ব্যথার ওষুধ টা
[21-07-2025 20:01] PPM 1: Eta shudhu ek din newar jonye, Deene du baar
[21-07-2025 20:01] PA: স্যার বলছিল যদি মাথা ব্যাথা করে তাহলে এটা খাবেন
[21-07-2025 20:02] PPM 1: Hain kintu soptahe ek du diner bashi noi. Kidney kharap hote pare
[21-07-2025 20:02] PA: ঠিক আছে স্যার
[23-07-2025 20.21] PA: বিয়ে দেওয়া যাবে। থ্যালাসেমিয়া পেশেন্ট টা
[23-07-2025 21.36] PPM 1: Bou ke janiye
[23-07-2025 22.19] PPM 4: Screening of the prospective spouse may be warranted.
[02-08-2025 19:39] PA: স্যার থ্যালাসেমিয়া পেশেন্ট টার রক্ত 7.1 বর্তমান আছে আজকে রিপোর্ট করলো।
হাসপাতালে ডাক্তার বলতেছে ব্লাড ভরতে লাগবে।
ব্লাড কি ভরা যাবে
[02-08-2025 19:52] PA: স্যার ব্লাড দেয়া যাবে কি
[02-08-2025 19:59] PA: ডাক্তার বললো ব্লাড দেয়া লাগবে ।
স্যার থ্যালাসেমিয়া পেশেন্ট টা কে ব্লাড দেয়া যাবেনা আপনি বলছিলেন।
কিন্তু এখানে তো ব্লাড দেয়া লাগবে।
[02-08-2025 19:59] PA: স্যার আমরা এখন কি করব
[02-08-2025 20:32] PA: স্যার আমরা এখন ব্লাড দিব ?
[02-08-2025 21:03] PPM 1: Blood dite habe ki habena sheta nirbhor korche roogir bortoman koshter upor.
Unar bortoman koshto ta ki ektu bistarito janate parle kichu bola jeto
[02-08-2025 21:04] PA: মাথা ব্যাথা ও জ্বর
[02-08-2025 21:06] PPM 1: Patient er group a eta post korun. Onyo group a post korle pore guliye jete pare
[02-08-2025 21:06] PA: ওকে
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