October 17, 2022
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
PATIENT HISTORY: Patient is a 30yr old female homemaker, who also worked as a plantation labourer (tobacco, potato farming) from 2015-2016 extensively for the past 2 yrs. For the past 6 months didn't work as a labourer because of her body pains.
From 2008, since menarche, her menstrual cycles were always accompanied by dysmenorrhea and menorrhagia (lasted for 9 days, each day needed 4-5 sanitary pads). Sometimes so severe pain that she would vomit and also experienced palpitation.
Along with that she also c/o a white smelly discharge accompanied by pain in the pelvis and a feeling of hot burning sensation. The discharge used to last for at least 20 days/month. In 2014, after a local Dr. gave her medicine only her pain (that was felt during white discharge) subsided. In 2019, with medications, her condition improved. At present, only 1-2 / month c/o pelvic pain and burning sensation, with scanty white discharge.
She got pregnant and first child delivery via C-section in 2014
Around 2016-17, she started c/o of a palpable (only when on empty stomach for long) non-tender moveable abdominal mass, which could not be detected by USG. Doctor said nothing is there.
Around 2017-2018, she started c/o continuous back pain exacerbated by heavy work or movement. Slowly the pain started spreading towards the whole of her back reaching the shoulders and also the hands and legs. It felt like a burning sensation along the vertebral column. All her jts of hands and legs are quite painful (reports she literally wants to crack open her joints) and felt like burning but not swollen. On doing massage and stretching the pain subsided a bit and she felt better. The pain severity increases during winter months or on lying for long under the fan. Dr. told her to do an X-ray and MRI of the LS spine which detected scoliosis. She was suggested to take medications which she could not continue after 5 days since taking those caused gastric problems. She started receiving Ayurvedic treatment in 2021 Sep which caused her much relief but had to discontinue due to financial issues.
In 2019, had to abort a fetus of 3 months as suggested by a Gynecologist who told her that there was the possibility of a fetal anomaly because she took quite a lot of medicines for her different ailments and for doing an MRI for her pain. After the abortion she no more c/o menorrhagia or dysmenorrhea. Menstrual bleeding last for 5 days now.
Since 2019, patient c/o diffused abdominal pain, acidity on having milk or milk tea or sugar cake (batasha), along with decreased appetite, abdominal bloating and mucus-laden loose stool. With medication symptoms improved but reoccurs 1-2 times/month.
For the past 6 months she c/o a piercing, throbbing, or electric-shock-like pain inside the head lasting for 2-3 mins happening once a wk.
Not a k/c/o HTN or DM
No addiction
CHIEF COMPLAINT AND Pt REQ.:
C/o intense back pain. joint pain, shoulder pain somewhat relief with massage and stretching and exacerbated with exposure to cold.
Even though in pain, still had to do household work. After doing intense work for long, she c/o extreme pain, and cannot lift her legs (especially right leg). Her right foot below the ankle feels cold and numb, with no loss of sensation.
C/o a piercing, throbbing, or electric-shock-like pain inside head lasting for 2-3 mins experiencing once a week.
C/o a palpable non-tender moveable mass in abdomen felt only in an empty stomach
C/o gastric problems
FAMILY HISTORY: She reported all her family members are healthy with no health issues
REPORTS:
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[23-03-2025 08:06] PA: Sir ai osudh chala kalin pregnancy report positive akhon ki karbo sir? lmp date 16 February aktu jadi balten'
[23-03-2025 17.53] PPM 1: Aei report anujai 👇
Oshudh ti te bishesh problems howar kotha noi
[23-03-2025 19:17] PA Sir baby Nile ai osudhta khaoya jabe?
[23-03-2025 19:55] PA: Sir osudhta bandho karle komore byatha khub hay hater joint payer joint kit ki kare chokhe ghum thake na matha byatha kare Jani na ar Kato din osudh khete habe.
[23-03-2025 20:46] PPM 1: Upor er link ta porle mone hocche khawa jabe
[02-04-2025 14:45] PA: Sir gyaino Dr dekhailam Dr Babu ballen baby neowa jabe abong triptomar osudhta khaowa jabe tate baby kono osubidhe habe na.tai akhon baby nebo .amar kon samosa Hale sir apnake janabo amar passe thakben ar janaben.
[10-06-2025 19.43] PA: Sir ami aita protidin kheye jachi akta kare
[10-06-2025 19:58] PPM 1: Scan er report ki?
[10-06-2025 20:04] PA: Sir report gulo sab share karbo kintu Dr babur numta kivabe ,muche diye pathate hay oitai Jani na tabe Dr Babu balechen sab normal ache.
[10-06-2025 20:33] PPM 1: [10/06, 20:11] Patient Advocate 33M Molar Pus: Sir apnake parsonaly pathailam
[10/06, 20:21]pm: Eta 19th May te kora!
Baccha norchena kabe ter peyechen?
[10/06, 20:22] Patient Advocate 33M Molar Pus: Akdino kichui bujhi nai.
[10/06, 20:23]pm: Tahole arekbar koriye newa dorkar.
Aer aager bacchar somoi kotodine ter peyechilen?
[10/06, 20:25] Patient Advocate 33M Molar Pus:
Bachar 11y kichui ,mane nai.
[19-06-2025 16:20] PA: Sir amar sara sarirta byatha ar jar sardhi ki medicin nibo sir jadi aktu balten?
[19-06-2025 16:22] PA: Sir sange matha byatha ache
[19-06-2025 19:40] PA: Sir paracetamole 650 mg khaoya jabe pregnancy je jarer ar matha byatha janno
[19-06-2025 20:00] PPM 1: Hain proti 6 hours ebong proti four hours temperature ta ekhane share kore janaben
[11-08-2025 16.59] PPM 1:
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