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:
[18-08-2025 21:03] PPM 1: [14/08, 12:33] Patient Advocate 33M lba: Sir, ajke amar 2 bar patla paykhana hayeche ki medicin neoya jabe? jadi aktu balten peye gas gas Mane hache akta medicin kheye khaoyar age.
[14/08, 16:49]cm: 👆Eta matha ghorano na howar oshudh
[14/08, 16:49]cm: Kono medicine dorkar nei 2 bar patla paikhanar jonye.
Next Paikhana tar chobi pathale bola jete pare
[14/08, 19:18] Patient Advocate 30f lba: Sir,sakale 2bar ar bikale 2bar sara dine 4bar paykhanar chobi deoya halo na pete gyas gyas Tai oi medicin kheyechi gyano diyeche 2mas age balche gyaser osudh sir,ors jal khaoya jabe?
[14/08, 19:29]cm: ORS o paikhana jol jol hole tokhon
[14/08, 19:34] Patient Advocate 30f backache: Paikhana jol jol ar rang kalo sir paikhanar rang kalo hay keno? IFA bori khachi tar janno ki?
[14/08, 22:03]cm: Hain
ORS khete paren
[17/08, 19:36] Patient Advocate 30f lba: Sir pet akhon bhalo ache kintu ar akta samosa kalker theke sada srab hache amar gyano dr.chutite ache aktu jadi balten upay?amar khub tention hache.
[17/08, 19:42]cm: Onyo arek jon Gynae daktar ke dekhiye neben
[18/08, 18:59] Patient Advocate 33M Molar Pus: Sir ajke ak gyano dekhailam uni amake tryptomer khete baron karlen kintu ami to oi medicin chara chalte pari na akhon ki karbo sir amar ,mobaile theke amar sab message amar chele delete kare diyeche
[18/08, 19:23] Patient Advocate 33M Molar Pus: Sir ami to apnake amar samosytha report share karechi Jani na sir apnar mobaile ache ki na
[18/08, 20:21] Patient Advocate 33M Molar Pus: Sada sraber janno ajke Dr dhyakhano.
[18-08-2025 21:06] PPM 1: 👆@PPM3 @PPM4 @PPM5 @PPM2 how to solve her problem? She's pregnant (in her case report it appears to be third trimester) and having leucorrhoea amd her new OBG has stopped her amitriptyline and she's anxious about it!
[18-08-2025 21:07] PPM 2: I cannot see previous messages unfortunately
[18-08-2025 21:08] PPM 1: Check out her PaJR case report. Her new OBG's prescription
[27-08-2025 10:45] PPM 6: Of course. This is a very sensitive and understandably anxiety-provoking situation for her. Here is a structured way to think about and solve this problem, combining immediate steps and strategic communication.
*Important Disclaimer:* This is for informational purposes and support. *This is not medical advice.* She must work directly with her healthcare providers. The goal here is to empower her to have the most productive conversations with them.
The problem has three interconnected parts:
1. *The discontinuation of amitriptyline* (causing anxiety and potential withdrawal).
2. *The symptom of leucorrhoea* (which needs proper diagnosis).
3. *The underlying anxiety* (which is now heightened).
Here’s a step-by-step approach to tackle this:
---
### 1. Immediate Action: Understand the "Why" Behind the Medication Change
The first and most crucial step is to get clarity from her new OBG. She should not suffer in silence or assume the worst. She has a right to understand her treatment plan.
* *Contact the OBG's Office:* She should call the nurse's line or schedule a brief follow-up call/appointment specifically to discuss this.
* *Prepare Questions:* She should write down her questions beforehand to stay focused. She can frame it collaboratively: "I trust your expertise, but I need to understand the plan so I can manage my anxiety better."
* "Can you help me understand the reason for stopping the amitriptyline? Is it a general rule for the third trimester or specific to my case?"
* "What are the potential risks of continuing versus the risks of stopping?"
* "I am experiencing increased anxiety and [mention any withdrawal symptoms like dizziness, nausea, sleep disturbances]. How can we manage this?"
* "Is there a safer alternative medication for depression/anxiety during pregnancy that we can consider?"
* "Can we involve my psychiatrist or previous doctor in this decision?"
*Possible Reasons the OBG Stopped It (for her to understand, not to assume):*
* *Standard Practice:* Some older OBGs may be more cautious and prefer to minimize all medications in the third trimester if possible.
* *Specific Risks:* While amitriptyline is generally considered one of the better-studied and relatively safe older antidepressants in pregnancy, very high doses near delivery have been associated with short-term withdrawal symptoms (jitteriness, respiratory distress) in the newborn. The OBG might be trying to avoid this.
* *The Leucorrhoea:* This is a critical point. If the OBG suspects the discharge is an *infection* (e.g., bacterial vaginosis, a yeast infection, or STI), they might want to rule out any medication side effects or interactions while treating it.
---
### 2. Addressing the Leucorrhoea
This symptom must be properly diagnosed to rule out any issues and to ease her mind.
* *It Can Be Normal:* Increased white or clear, non-irritating discharge (leukorrhea) is *extremely common* in pregnancy due to increased estrogen and blood flow to the vaginal area.
* *It Can Be an Infection:* If the discharge is yellow/green, has a bad odor, is accompanied by itching, burning, or redness, it is likely an infection that needs treatment to protect her and the baby.
* *Action:* She must describe the discharge in detail to her OBG or get it tested. The OBG likely already has a plan for this based on the case report. Knowing if it's normal or easily treatable will remove a major source of anxiety.
---
### 3. Managing the Anxiety and Potential Withdrawal
Stopping an antidepressant abruptly is never advised. She needs support while her body adjusts.
* *Communicate Symptoms:* She must be very clear with her OBG about the severity of her anxiety and any physical withdrawal symptoms. Phrases like "I cannot function" or "my anxiety is debilitating" are important for the doctor to hear.
* *Non-Medication Strategies (To Use Immediately):*
* *Therapy:* If she doesn't have a therapist, asking her OBG or PCP for a referral to a *perinatal psychiatrist or therapist* is essential. They specialize in exactly this.
* *Mindfulness & Breathing:* Apps like Calm, Headspace, or Insight Timer have short exercises for panic and anxiety.
* *Gentle Movement:* A walk outside can significantly reduce anxiety.
* *Support System:* Leaning on you all (@~ahana :), @~ayushi tandon, etc.) is huge. Encourage her to talk about her fears without judgment.
* *Advocate for a Taper:* If the decision is to stay off amitriptyline, she should ask if she can *taper off slowly* rather than stop cold turkey, to minimize withdrawal. If the decision is to stay on medication, she should discuss the safest option.
---
### 4. The Power of a Second Opinion & Collaboration
If the conversation with her current OBG is unsatisfying or dismissive of her mental health, *she should absolutely seek a second opinion.*
* *Find a Perinatal Psychiatrist:* This is a psychiatrist who specializes in mental health during pregnancy and postpartum. They are the best experts to weigh the risks of medication vs. the risks of untreated mental illness. They often work collaboratively with OBGs.
* *Her Previous Doctor:* If she had a good relationship with the doctor who prescribed the amitriptyline, she can request that her records be sent to the new OBG to facilitate communication.
### Summary: A Script She Can Use
"Hi Dr. [OBG's Name], thank you for your time. I want to follow up on our last appointment. I understand you've stopped my amitriptyline, and I want to make sure I'm following the plan correctly. Could you help me understand the primary reason for this change? I'm experiencing a significant increase in my anxiety and [list symptoms], and I'm worried about how this will affect my pregnancy. I also wanted to ask about the discharge I'm experiencing—should I be concerned about that? My mental health is very important for me and my baby's well-being, and I'd like to discuss all our options, including a slower taper or a referral to a perinatal mental health specialist. Thank you for helping me through this."
### How You Can Help (@PPM3, @PPM4 @PPM5 @PPM2)
* *Listen without judgment.*
* *Help her write down her questions and symptoms* before she calls the doctor.
* *Offer to go with her* to an appointment for moral support (if she wants).
* *Help her research* names of perinatal psychiatrists in her network.
* *Distract her* with positive activities.
The key is to move from fear to *informed action. Her health and the baby's health include her *mental health. A good medical team will understand that and work with her to find the safest balance.
[27-08-2025 10:57] PPM 1: Thanks. Very useful.
@PA apnar patient er somosya ta aekhon kemon ache?
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