Case of a 35/F from West Bengal

Hello, This is Geetanjali.

This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent. Here we discuss our individual patients problems with an aim to solve the patient’s clinical problem with collective current best evident based input.

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This is a telemedical case report of our patient.

I have been given this case to solve in an attempt to understand the topic of “patient clinical data analysis” to develop my competency in reading and comprehending clinical data including history, clinical findings,investigations and come up with diagnosis and treatment plan.

The patient is a 35 F from Malda, West Bengal , assistant professor by occupation.

(The patient history was taken over the phone)

CHIEF COMPLIANTS :

Lower back pain ( since 2020)

Knee pain (since 2020)

Menorrhagia ( since 1 year)

HISTORY OF PRESENTING ILLNESS:

She was apparently asymptomatic till 2020

Lower back pain (since 2020)

Insidious in onset

Progressive in nature

Aggravated on sitting upright to use computer

Relieved on using counterirritants (volini) and sleep

Knee pain (since 2020)

Non radiating

Insidious in onset

Progressive in nature

Right Knee joint pain in prominent

H/o locking present (medication prescribed but failed to work)

Aggravated in the past 6 months and on standing

Received pain on adequate rest , usage of counterirritants and exercises given by PT

Menorrhagia started 1 year after delivery

Clots present (2- 3 cm in size , increased after delivery)

Bleeding increased in the first 2 - 3 days since just 2021

Dryness around the lips is present since 7 - 8 months

- aggravated on less water intake and not moisturized

- leads to redness and itching

- lips get sealed and leads to Bleeding

MENSTRUAL HISTORY :

Menarche : 13 years

No of days per cycle: 7 / 30 days per cycle

No of pads used (before mennorhagia) : 3 - 4 pads per day

No of pads used currently : 5 - 6 per day

Clots present (increased after labour to 2- 3 cm in size)

Menorrhagia present in first 2 - 3 days since June 2022

-(OBS HISTORY):

Had an LSCS done in JULY 2021

1 daughter ( live and healthy)

Still breast feeding ( causing sleep disturbances)

No abortions

Appetite reduced over time

Blotting present and increased during sleep

MARITAL HISTORY :

Married in 2018

Uses oral contraceptives

No h/o of fertility treatments

FAMILY HISTORY :

Mother is a patient of osteoarthritis since age of 40

Father is a known case of diabetes and has had open heart surgery done.

PAST HISTORY:

Known case of hypothyroidism

Uses prescribed medication - 25 mcg

Initial dosage changed from 12.5 mcg , 25mcg and 50 mcg

Easily lethargic , fatigued and hair loss presnt since diagnosed with hypothyroidism

Taking iron tablets since 3 months ( no change in hb levels)

Dizziness present since 1 year

Low BP rarely present (100/60)

PERSONAL HISTORY:

Height - 5 feet

Weight- 44 to 45kg

- lost around 5 kg weight post partum

Regular bowel movements

- Takes Pantom tablets for acidity and bloating ( 13 - 14 per month)

Diarrhea associated with bloating present .

DAILY ROUTINE

Monday to Friday:

Prepare her child for school during 8.30 -9.30 am, 6-7 hours for university work, rest for 1 hour, 2 hours miscellaneous work at home, 1-2 hours official or personal work in computer, 7- 8 hours sleeping.

Saturday and Sunday:

Spending time with her child throughout the day, Rest after lunch for 2 hours, 3-4 hours for Miscellaneous work outside and inside home, 1-2 hours official or personal work, 7- 8 hours sleeping.

• Wake up in the morning at 7.30-8.00 am

• Tea time : 8.30 - 9.00am

• Breakfast at 9.30 to 10 am

• Lunch in between 12.30 to 1.30pm.(when stay at home)

• Office time on an average 11.00 am – 6.00 pm.

• Tiffin at 7-7.30 pm

• Dinner at 9.30 to 10 pm.

• Go to sleep on an average at 12.30 - 1.00 am

DAILY DIETARY CONSUMPTION

Sunday:

Breakfast: Luchi or paratha and Alu sabji and Tea.

Lunch: Rice, Fish, seasonal vegetables