This is a HIPAA de-identified open-online-patient-record with initial information in patient's voice, posted here after collecting informed patient consent (form downloadable Click Here) by BMJ Elective Student.
1. Age: 49 years
2. Description for current problems: Slip disc L4-L5 level
i. Intermittent low back pain (comes on and off)
ii. Dragging type of pain the left leg
iii. Numbness in the lower left leg, and toes of left foot
iv. Intermittent pins and needle sensation on the sole of both feet.
v. Often during sleep, I feel numbness in the area between waist and the right knee and improves as as I change my posture. I also get the same sensation when I stand up for a long time.
vi. I often have pain the shoulder and right hand due to spondylosis. This improves after doing Yoga.
Vii. I often feel pain in the chest and back due to gas problem which sometimes gets worse.
3. When is your problem started?
- From the winter of year 2014.
4. What medications are you currently on?
- I am not taking any medicines right now. However, I attached the prescription of all the previous medications which I stopped 2 months back. I took those medications from the early winter of 2017 till the spring of 2018. I stopped these medicines because the list was too long and was not improving my health condition.
5. Detail history of present illness:
i. I am suffering from intermittent chronic low back pain.
ii. I got typhoid fever in 2011 that cured after taking treatment.
iii.I fell down from the broken low bench in 2007/08 and sustained injury to the coccyx. I applied ice pack there followed by an Xray which revealed no problem.
iv. In the winter of 2014- I was taking physiotherapy due to back pain and leg pain. Right after taking physiotherapy for two days, I got injury/pain to the nerve in the leg while walking. After walking with this for a while, I fell down and doctors advised traction.The numbness in the legs had started right from that point of time. I was bed-ridden for 15 days that time. An MRI was done. A local doctor advised for an operation.But without going for the operation, I went to a big tertiary care hospital in Delhi.
v. In the tertiary hospital, doctor advised some medications and some physiotherapy to be exercised. Till now, I am following that exercise regularly.
6. Family history:
- My father has been a patient with arthritis and currently his RH (?) factor is positive and he is taking treatment for that.
- My father was diagnosed with stomach cancer at the age of 75 and currently, he is free from the cancer.
- My father is currently aged 83 years and can not remember properly and repeat the same words.
- My elder brother was a patient of epilepsy/seizure and he committed suicide at the age of 30.
- My grandfather died due to stomach cancer at the age of 55.
- My mother had not significant medical history and she died due to road traffic accident at the age of 64.
- My parents, brothers none of them have any history of diabetes.
- Daughter of my younger was diagnosed with epilepsy/seizure at an early age which was improved with medicines. However, her IQ is very low.
- I, myself, had fell over a cooking vegetables which had severely burnt my belly.
- I had a pox at the age of 4 and 20 years. At the age of 4 years, I got fracture to the right hand
7. Personal/ social history:
- I often get stressed out with any minor stressful situations.
- For any familial or social matters even if that is small, I take over unnecessary pressures on myself.
- I can not calm down myself if someone speaks anything illogical and get anger. Even while reading any illogical thing in newspaper or watching TV news I get headache (jhimjhim). However, now-a-days I am trying to control over this. Despite this nature, I often remain calm with other people. But I do get angry sometimes and can't get control over that time.
- I don't like flattery even if that is beneficial to me.
8. Addiction history:
- There was a time I used to take pan with tobacco. Otherwise I don't have any history of taking other illicit drugs or alcohol.
9. Allergy history:
- I don't have any significant history of allergy, however, I notice red lesions in the thigh during the winter season. But that improves later.
10. Other significant history:
- Till the age of 10, I used to get large abscess int he heads but that would reduce later.
- From the age of 18/19 years, I started getting on and off "gota gota" (?) in the face which is still there.
Bangla version:
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