03-04-2025
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.
[03-04-2025 22:33] PA: Sir, ami nijer akta case history lekhar chesta korechi . Seta ei group a pathalam
[04-04-2025 07:00] PPM 1: Thanks. Please share the above hand written version in text if possible for our case reporting team as hand written version will be difficult for them to google translate and understand. Also handwriting is a potential patient identifier and can compromise her confidentiality.
Please don't address the patient by name or share any of her identifiers here.
After reading the hand written note I have provided a brief summary in the title
[04-04-2025 07:01] PPM 1: Any clinical images of her hair fall areas of the scalp would be useful
[04-04-2025 09:24] PA: Okay
[04-04-2025 11:55] PA: Particulars:
Age: 24 years
MBBS Student (Final Year)
Residence: Coochbehar, West Bengal (Currently living in College Hostel, Kolkata)
Complaints:
1. Gastrointestinal Issues:
Frequent abdominal pain, bloating, acidity, and loose stools. A slight change in dietary routine triggers these symptoms.
Symptoms have been present since adolescence but have worsened in the past few years.
Diagnosed with Irritable Bowel Syndrome (Diarrheal type) in 2024.
2. Recent Symptoms (Last 15 Days):
Feeling of stomach fullness in the evening, lasting through the night, along with loss of appetite.
Symptoms appeared during final-year exams (ongoing for the past month).
Slight relief with PPIs.
3. Headaches:
Frequent headaches, primarily in the evening.
4. Psychological Issues:
Experiencing depression for the past five years, since entering medical college, mainly due to academic struggles.
Symptoms have worsened significantly over the last year.
Difficulty concentrating on studies or engaging in previously enjoyable activities like drawing or writing.
Increased mobile phone addiction since entering medical college.
Experiencing suicidal thoughts.
5. Polycystic Ovary Syndrome (PCOS) (Diagnosed in 2017):
Menstrual cycles were usually regular but have become irregular over the past three months.
Associated symptoms: Acne, male-pattern hair loss, and facial hair growth (male-pattern hirsutism).
6. Vision Problems:
Diagnosed with myopia.
Last power and retinal check-up was in May 2024.
Current Power:
Right Eye: -4.25 (S), -0.75 (C)
Left Eye: -3.75 (S)
Medications:
1. Propranolol 10 mg BD – Taken for the past month for exam-related palpitations. Stopped two days ago after the exams ended.
2. Escitalopram 10 mg – Taken at bedtime for the past 15 days under psychiatric guidance.
Daily Routine (Mostly):
9 AM: Wake up, freshen up, have breakfast.
1 PM: Lunch, followed by bathing.
4 PM: Evening nap.
7 PM: Tea and evening snacks.
10 PM: Dinner.
2 AM: Sleep.
