49 yrs old female w/c/o whole abdomen burning sensation

 NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.  

PATIENT HISTORY: Pt is a 49 yrs old female, homemaker.

Since childhood, pt c/o constipation (passing normal stool after 2-3 days). Doing Ayurvedic syrup causes relief.

In the year 2003, pt c/o of her whole body edematous, pitting edema noted, acute insomnia, malaise. Dr found her TSH level high and diagnosed her with Hypothyroidism. Took medication and follow-up reports showed TSH normal. At that time, wt was 75 kgs (now 62 kgs).

In 2008, she c/o insomnia, a burning sensation in the sole of her feet, along with gastric problems (whole abd burning sensation, bloated abd, incomplete defecation), and itchiness in the vagina. Her PP was 300 and Dr made a diagnosis of DM. On medication for the same.

In 2015, when in Hyd for her husband's checkup, she was diagnosed with fatty liver.

In 2017, during routine checkup, her cholesterol lvl was high. Under control with medication.

For the past few months the burning sensation in whole abd has increased in frequency. It happens more when she is hungry, or when she eats spicy foods. 6-7 hrs later, after defecation she feels relieved. She reported the stool is mucus laden.

For the past 2-3 yrs, she is taking medication for gastric issues.

1-1.5 yrs ago, she c/o severe headache in the temple region almost all day (?migraine), intensifying with notice, brightlight, movement. Relieved with rest. After taking medication for 6 months, her symptoms reduced a lot. 

For the past few months, she c/o localized pain in left side of lower abd, which lasts fro few mins and goes away on its own.

Pt is diabetic since 2012, under control with medication.

ADDICTION: eats paan 1-2/day, started 6 months ago (peerpressure)

Author Dr Himaja -

49 year old female born by natural delivery on 05-06-1973. Born and bought up in coochbihar North Bengal.

Milestones achieved normal.

Childhood was pleasant. Went to school by walk 1.5kms near to home. Comes back home and played games like coco, jumping,running, finishes homework and goes to bed.

She lives with her family - 9 siblings,parents and grandparents all live together 

At age 11 she lost her father due to heart stroke secondary to hypertension.

She is very close to her younger brother during her childhood but the same relationship wasn’t maintained after he got married.

She had evening tuitions in 9th standard, fell in love with the teacher. Family was against to this and her elder brother physically tortured her. She came out of the house and married the love her life at age 16.After marriage she had mental torture from her in laws but the relations became smooth after the birth of first baby. Within an year of marriage she got pregnant but keeping the age in mind and after mutual decision she aborted the baby.

She completed her +1 and +2 in arts after marriage 

At age 19 that is in 1993 she gave birth to a baby girl by normal delivery.

In 1997 her husband was appointed as forest officer and they moved to staff quarters and lived happily. 

In 1999 she gave birth to her second daughter by normal delivery. 

In 2001 she had facial puffiness, edema of both upper and lower limbs, went to hospital and was diagnosed with Hypothyroidism. 

In 2008 she had insomnia, burning sensation in feet and legs, slow healing of wounds and diagnosed with type 2 DM and was started on medication.

In 2010 she went for a routine checkup and doctor advised her for fasting lipid profile. Found her cholesterols levels were high and she started on medication tab atorvastatin 10mg

In 2010 her husband was diagnosed with cad which worried her so much and took lot of stress but eventually came out of it believing in god.

Marital life was good and they haven’t had age difference issues in their life. Her husband has anger outbursts occasionally and small quarrels on differences for example she likes to have fast food but he likes to stay healthy etc. she is very much interested to do a job but her husband had different views on it and doesn’t like girls stepping out of home and hence she remained as house wife took care of household chores and looked after family.

In 2023 She married of her elder daughter which made her so sad and also happy to send her to in laws home.

Daily routine- usually wakes up by 7.30-8am cooks breakfast like moori,chichire,Chura and have breakfast with tea at 10am, fruit at 11am. Cooks and have lunch around 2pm rice with non veg everyday like chicken fish mutton or egg. Takes rest for 30 minutes. Wakes up and have a cup of green tea after which she goes for an evening walk for 1-2 hours for 5-6kms. Comes back home, have snacks and take rest for a while, cooks dinner and have roti around 10pm. Occasionally have very little amount of alcohol but she feels abdominal burning sensation and so she avoided it in recent times. She had a habit of eating pan after every meal.

The routine is almost the same since her marriage and wasn’t changed or affected till date.

CHIEF COMPLAINT AND PT REQ: 1) Pt is diabetic, high cholesterol

2) c/o whole abd burning sensation

FAMILY HISTORY: 

Father - HTN, constipation. Died at age of 50 due to brain attack

Mother - no health issue

Elder brother - DM, CAD

Elder brother - DM

REPORTS: