30F with back pain

 

PATIENT HISTORY: Pt is a 30 yr old female homemaker, who also worked as a plantation laborer ( tobacco, potato farming) from 2015 -16 extensively and for the past 2 yrs. For the past 6 months didn't work as a laborer because of her body pain.

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 abd. mass, which could not be detected by USG. Dr. 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, pt c/o diffused abd pain, acidity on having milk or milk tea or sugar cake (batasha), along with decreased appetite, abd. 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. jt 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 rt leg). Her rt 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 happening once a wk.

C/o a palpable non-tender moveable mass in abd 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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