52 yrs old female w/c/o recurrent ulcers, pain on rt knee and hip

PATIENT HISTORY: Pt is a 52 yrs old female, working as a school teacher.

BIOLOGICAL COMPONENT: Since childhood, the patient suffers from constipation (2-3days later incomplete defecation, hard stool)

At the age of 19, she c/o heavy bleeding while passing stool followed by splinter hemorrhagic pain 1-2 hrs after defecation of hard stool which made it impossible to sit also. The doctor prescribed medications that stopped the bleeding. Now, no more bleeding, only when suffering from constipation c/o pain while defecating.

In 1999, she started c/o a continuous whole right side pain (from head to toe) which would intensify on working and at night while going to sleep(the pain would be so severe that she could not fall asleep also sometimes). After suffering for a few months and taking medicines from a local Doctor slight relief. She went to Vellore to seek further advice where Doctor said the pain was due to some minor neuropathic problem. Medications were prescribed taking which would provide temporary relief. Sought no further treatment.

Hypothyroidism was detected while she was in Vellore. Since then taking Thyronorm tab. (first few years 50 mcg then 100 mcg).

In the year 2014, after reading an article about breasts ca. she did a self-examination. She thought she could feel a lump in the lat. quadrant of rt breast. But Doctor said there is nothing. After 1 year she started c/o pain. Dr. diagnosed it to be a fibroadenoma of the breast. In 2016 Jan, a lumpectomy was done for rt breast. Dr. said there was also a small lump in the left breast which needs no operation.

In 2014-15, she started c/o gastric problems (nausea, headache, burps, abd bloating) frequently. Endoscopy detected gastritis. Medications were prescribed taking which will cause some relief.

A few months later, she started vomiting (whatever she ate or drank, 15-16 times sometimes in a day) and sudden diffused abd pain (lasting for a few mins to hrs, frequently after fatty meal), mostly in the upper rt quadrant and center of abd spreading to the back and center of her chest. She frequently would be hospitalized. Had to keep Aciloc and Ondem inj. in the home. After staying like this for a year or two, she visited a gastroenterologist. USG revealed gallstone.

On July 2019, a cholecystectomy was done. For a few months, she was feeling alright (no more vomiting, abd pain, or gastric issues). Then again she started complaining of localized pain in the upper abd. The pain would mostly start at midnight/dawn which would disturb her sleep. So much so that she needed painkillers. Dr. did a colonoscopy and endoscopy which revealed a colon ulcer (2020) and her Hb level was also low (Previously she had mentioned since childhood her Hb lvl always used to remain on the lower side, she claims she had no access to good quality nutritious food during childhood). The biopsy report was normal. Medication and strict control of diet were recommended (avoidance of oily spicy fried foods, avoidance of citrus foods, etc.). Following which gave her some relief for a few months.

6 months later she went for a check up and Dr said no more ulcer. Still, she went to Hyderabad for reconfirmation. They also reported no ulcers and gave Iron dextran inj. For 1 year she had no complaints.

In 2020, c/o rt shoulder pain on movement. Dr. diagnosed it as tendonitis. On doing physiotherapy the pain subsided. Earlier, she also had pain in lt shoulder which reduced on doing physiotherapy.

Then in 2021, she again started c/o localized pain in upp abd(starting at midnight, but this time less severe). Her Hb lvl again reduced a bit. Dr. performed a spiral enteroscopy. A duodenal ulcer and a colon ulcer were detected. Dr. prescribed Pentasa enema, Cremaffin syrup (since then she continues it, whenever stops again the problem of constipation) and Wysolone tab (40mg then 20 mg 10 mg 5mg finally stopped). Her biopsy report was normal.

She c/o pain (claims it does not feel like muscle pain) in her rt hip joint since 1999, which would reduce on resting or on compression or oil massage. Doing physiotherapy for a few wks and exercising she felt no pain from Sep 2022 to Mar 2023. Now again c/o pain which starts from her rt hip jt and travels down towards her knee. She mentioned 1-2 yrs ago Doctor diagnosed disc herniation in the lumbar spine.

For the past 2-3 months c/o epigastric burning sensation (can't specify any fixed pattern, lasts for only 2-3 secs, 2-3 times a wk).

She was told to stop taking Wysolone by Physician. After she stopped Wysolone, she c/o extreme localized stabbing epigastric pain lasting for 10 mins max. Her Hb came down to 13.2 from 14.6 gm/dl. No further treatment was done. At present, the pain occurs 1-2 times/wk and lasts for 2-3 secs or 1-2 mins. She also started c/o severe pain in the rt knee (more severe after walking, climbing stairs or trying to fold her legs) and rt hip joint after stopping Wysolone. Decreases a bit at night while resting or doing a hot oil massage. She also noticed some popular rashes emerging on her face and left hand.

Denied h/o HTN or DM. No addiction history.

Menstrual history: Menarche at age of 13-14. Menopause at 8-9 months ago. Normal regular cycle. No menorrhagia or dysmenorrhea was reported.

PSYCHOSOCIAL COMPONENT: Pt belongs to a very humble family. During her childhood had no access to enough food. Her dad being lazy and not willing to work would sit idly at home. Seeing this her mother sold all her jewelry and used to do a job of sewing to make ends meet.

Whenever her mom would get a job for her father after going to work for a few days he would leave it and stayat home. These often lead to quarrels.

In 1990, when she turned 18 yrs, her family decided to marry her off. At the final stage of getting married, she told her mom that she loves her Economics teacher and wants to marry him. Her mom denied giving permission. Still, she chose to marry her boyfriend (teacher) instead of the groom. Since her mom had gone through so much trouble for her and her siblings she was very upset about marrying against her will and permission.

On the day of her marriage, her to-be husband's ex came to the marriage hall to stop the marriage. Her husband and his ex both insulted her which lead to a quarrel.

1 month later, one night while going to sleep, a neighbor (female) called her husband to stay with her tonight because she was feeling lonely and scared to sleep alone in the house. This upset pt a lot. She realized this is not something new.

Her husband's relationship with his father was not good hence he kicked them out of the house one day. They started living in the husband's friend's house. One night she caught her husband kissing one of their relatives. She decided to leave her husband. The husband begged for forgiveness. So, she continued staying with him.

Since at that time her husband had no fixed job, they had to depend on whatever tuition he could get. He would be busy with work and had no time for her.

A few months later she became pregnant. She went to stay in her father's room. Her husband stopped coming to visit her or keeping in touch with her. He wrote a letter saying he wants to end the marriage. She fell very ill hearing this. Then his friends talked with him and convinced him otherwise. Soon after he got a job. She gave birth to their son. He became so busy with work that he had no time to talk with her also apart from what groceries he should buy from the market. He started writing stories. On reading those he realized it is about his ex and him. She felt left out and unworthy.

In 2011, she tried committing suicide by hanging herself. Her husband saved her at the nick of time. A family meeting was arranged to resolve everything. She requested him to spend some time with her and give up writing about his ex, which again lead to many quarrels and fights. Her husband started spending some time with her.

2 yrs later she gave birth to their daughter. She realized that she needs to do a job to support her family and gain importance in her family. She soon got a job.

2-3 yrs ago, once she got to know from a relative that he had posted a writeup in social media about him and his ex. She felt very upset and tried ending her life by taking an overdose of sleeping pills. Luckily, her attempt failed.

1 yr ago, she got to know from an acquaintance that her husband has been stopped with his ex. In the meantime, by his way of speaking and through his poems she realized he had fallen in deeper love with his ex. He started ignoring her completely.

Pt confronted him and explained everything from the beginning. Her husband finally understood her situation and since last one year is looking after her, and sending time with her.

She claimed to be under severe stress and mental pressure for the past 1 year, Now she is happy.

Her relationship with her daughter is very good. They want to get her married first before their son but are not able to.

Her relationship with her son is not that good. They wanted him to marry later but his girlfriend is putting pressure on him to get married. Also, both of their children do private jobs. This is also causing a lot of stress and tension for her.

CHIEF COMPLAINT ANF PT REQ: 1) c/o recurrent ulcers (?stress ulcers)

2) Pain in rt knee joint for the past 1 yr aggravated for the past few days, restricting her movements

3) recurrent pain in rt hip jt since 1999, aggravated since past few days, restricting her movements

4) c/o painful inflammation of glands in the neck (?tonsils) accompanied by papular rashes on the face and hand

4)She is fed up with following such a strict diet. Wants to lift most diet restrictions

FAMILY HISTORY: Father - HTN

Mom - shoulder pain, died at age 48 (suicide)

Mom's dad - DM, died due to kidney failure

Younger sister - shoulder pain

DIET: সকাল সাড়ে সাতটা ও সন্ধ্যা ৬টায় লাল চায়ের সঙ্গে মুড়ি-খই মিশিয়ে।

সকাল ১০টা, দুপুর ২ টা, রাত ১০টায় তাজা মাছের পাতলা (তেল, মশলা কম দিয়ে) ঝোল বা পাতলা মুশুরি ডাল আর কোয়াস,আলু, গাঁজর দিয়ে সবজি।

এছাড়া কলা-মুড়ি বা ইদানিং তরমুজ কিংবা সকাল সাতটার আশেপাশে দুটো মেরী বিস্কুট।

এই diet দুই মাস থেকে চলছে।

Before that, as instructed by Doctor didn't drink milk for the past 1.5 yrs. But later started consuming milk too. Her diet included everything ranging from healthy to oily spicy fried food till 2 months ago.