Case of a 47 years old woman with hip pain.
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REFERENCE- https://ssahamedicalcases.blogspot.com/2022/08/patient-history-pt.html?m=1
This is the case of a 47 years old lady, who is a chartered accountant by profession and a resident of Bhopal.
CHIEF COMPLAINT
The patient has the chief complaint of pain in the hip bone from childhood.
HISTORY OF PRESENTING ILLNESS
The patient was apparently asymptomatic at the age of 13 years when she started experiencing pain in the right hip joint. The pain would start on standing for long hours (2-3 hours). The pain was of piercing and stabbing type. It would radiate to the heel on the same side. It would be so severe making the patient not being able to walk. The pain would get relieved only after a rest of 3-4 hours. The patient would also experience pain on wearing high-heeled footwear. It was not associated with any swelling of the joint or nausea and vomiting or fever. There was no change in gait and the patient walked normally.
The patient started practising yoga and various exercises, which helped her get some relief.
At the age of 21 years, the patient went to the doctor for hip pain. An X-ray was taken and nothing significant was found.
For the past 3-4 days, the patient is complaining of increased pain in the hip bone. The patient describes the pain starting from the centre of the hip bone and radiating, upwards to the lower back and downwards from both the legs to the heels. It is continuous in nature. The pain would increase after strenuous work, standing for even 1 hour and lifting heavy objects, and relieved only after taking a paracetamol tablet and rest for 3-4 hours. The pain is of piercing and stabbing character. The patient describes the pain as being very severe and causing reduced mobility and inability to walk during the pain. It is not associated with any swelling, nausea or fever. The patient has a history of sitting with her legs folded for a long time from childhood.
History of cervical spondylitis since 2015. In 2019, the frequency increased to 4-5 times a month, with neck pain for 5-6 days. The episodes were associated with neck stiffness and pain, headache and blurred vision.
Since 2020, the patient complains of digestion problems. She had 6-7 episodes of food poisoning associated with nausea, vomiting and diarrhoea. She would get some relief by consuming buttermilk.
HISTORY OF PAST ILLNESS
History of contracting COVID twice, once in the first wave and the next time in the second wave.
Between Jan 2021 and July 2022, the patient gained 10 kgs.
History of chronic sore throat and cough, which subsided on its own, 6-7 years ago.
Not a known case of DM, hypertension, asthma, TB, Thyroid condition, CVD, or Epilepsy.
SURGICAL HISTORY
2020- Hysterectomy due to uterine fibroids.
FAMILY HISTORY
Mother- In 1988 - got operated on for ectopic pregnancy. She was given a blood transfusion because of which she contracted Hep C. Also complained of episodes of food poisoning.
Father- He was a heavy user of tobacco and paan masala. Detected with Terminal Pancreatic ca. In Sep 2018, passed away at the age of 72 years.
PERSONAL HISTORY
DIET- Normal. Irregular and less from the past 3-4 days.
APPETITE- Vegetarian diet. Consumes eggs occasionally.
SLEEP- Adequate
BOWEL
AND BLADDER MOVEMENTS -
Bowel movements - History of constipation from childhood. Relieved by practising yoga and eating fruits. Remerges if yoga is not done for 20 days.
Bladder movement - History of increased urination from childhood due to less control over the bladder. Reduced intake of water causes burning micturition.
ADDICTIONS-none
ALCOHOL-no
SMOKING-no
ALLERGIES- Dust allergy from childhood which subsided on its own.
OCCUPATION - The patient has an occupation which involves sitting and working on the computer, in one place for a long time.
PAST REPORTS
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