Template for PaJR user driven history taking to build the initial case report problem representation

Questions for the patient advocate;

Please describe your patient's sequence of events that led to the current problems. Please begin the sequence of events from the time your patient had absolutely no problems at all. 

Please describe your patient's hourly  routine over 24 hours when he was perfectly alright 

Next please describe what happened to his hourly 24 hour routine once the disease took hold on his life 

Please mention specifically which part of the patient's hourly routine was disrupted 

What are the patient's current requirements from us like if we had to give him a single medicine which problem would they prefer it to address?

Please post the patient's clinical photo of abdomen and arm muscle as demonstrated below in the image here:

and post the photo of any other problematic bodily area taking care such that it doesn't reveal the patient's identity

Task for PaJR team:

Prepare the patient's problem list and perceived requirements list in order of priority 

Formulate a plan for each one of the problem requirements  listed

More here on how they may create a dynamic case report (EHR)  : 

https://sites.pitt.edu/~super1/lecture/lec53671/002.htm

Bengali:

রোগীর অ্যাডভোকেটের জন্য প্রশ্ন;

অনুগ্রহ করে আপনার রোগীর ঘটনাগুলির ক্রম বর্ণনা করুন যা বর্তমান সমস্যার দিকে পরিচালিত করেছে। আপনার রোগীর একেবারে কোন সমস্যা না হওয়ার সময় থেকে ঘটনাগুলির ক্রম শুরু করুন। 

অনুগ্রহ করে আপনার রোগীর 24 ঘন্টা ধরে তার প্রতি ঘন্টার রুটিন বর্ণনা করুন যখন সে পুরোপুরি ঠিক ছিল 

এর পরে অনুগ্রহ করে বর্ণনা করুন যে একবার রোগটি তার জীবন ধরে নেওয়ার পরে তার প্রতি ঘন্টা 24 ঘন্টার রুটিনে কী ঘটেছিল 

রোগীর প্রতি ঘণ্টার রুটিনের কোন অংশটি ব্যাহত হয়েছে তা বিশেষভাবে উল্লেখ করুন 

আমাদের কাছ থেকে রোগীর বর্তমান প্রয়োজনীয়তাগুলি কী যেমন আমরা যদি তাকে একটি ওষুধ দিতে হয় তবে তারা কোন সমস্যাটি সমাধান করতে পছন্দ করবে?

অনুগ্রহ করে রোগীর পেট এবং বাহুর পেশীর ক্লিনিকাল ফটো পোস্ট করুন যেমনটি নীচের ছবিতে দেখানো হয়েছে:

এবং অন্য কোনো সমস্যাযুক্ত শারীরিক অংশের ছবি পোস্ট করুন যাতে রোগীর পরিচয় প্রকাশ না হয়

PaJR দলের জন্য কাজ:

অগ্রাধিকার অনুসারে রোগীর সমস্যা তালিকা এবং অনুভূত প্রয়োজনীয়তার তালিকা প্রস্তুত করুন 

তালিকাভুক্ত প্রতিটি সমস্যার প্রয়োজনীয়তার জন্য একটি পরিকল্পনা প্রণয়ন করুন

তারা কীভাবে একটি ডায়নামিক কেস রিপোর্ট (EHR) তৈরি করতে পারে সে সম্পর্কে আরও এখানে: 

https://sites.pitt.edu/~super1/lecture/lec53671/002.htm

Hindi:

रोगी अधिवक्ता के लिए प्रश्न;

कृपया अपने मरीज़ की उन घटनाओं के क्रम का वर्णन करें जिनके कारण वर्तमान समस्याएँ उत्पन्न हुईं। कृपया घटनाओं का क्रम उस समय से शुरू करें जब आपके मरीज को बिल्कुल भी कोई समस्या नहीं थी। 

कृपया 24 घंटों में अपने मरीज़ की प्रति घंटा दिनचर्या का वर्णन करें जब वह बिल्कुल ठीक था 

इसके बाद कृपया बताएं कि एक बार जब बीमारी ने उनके जीवन पर कब्ज़ा कर लिया तो उनकी प्रति घंटा 24 घंटे की दिनचर्या का क्या हुआ 

कृपया विशेष रूप से उल्लेख करें कि रोगी की प्रति घंटा दिनचर्या का कौन सा भाग बाधित हुआ था 

मरीज की हमसे वर्तमान आवश्यकताएं क्या हैं, जैसे कि अगर हमें उसे एक ही दवा देनी हो तो वे किस समस्या का समाधान करना पसंद करेंगे?

कृपया रोगी के पेट और बांह की मांसपेशियों की नैदानिक ​​तस्वीर पोस्ट करें जैसा कि नीचे दी गई छवि में दिखाया गया है:

और देखभाल करने वाले किसी अन्य समस्याग्रस्त शारीरिक क्षेत्र की तस्वीर इस तरह पोस्ट करें कि इससे रोगी की पहचान उजागर न हो

PaJR टीम के लिए कार्य:

प्राथमिकता के क्रम में रोगी की समस्या सूची और अपेक्षित आवश्यकताओं की सूची तैयार करें 

सूचीबद्ध प्रत्येक समस्या आवश्यकता के लिए एक योजना तैयार करें

वे डायनेमिक केस रिपोर्ट (ईएचआर) कैसे बना सकते हैं, इसके बारे में यहां और जानें: 

https://sites.pitt.edu/~super1/lecture/lec53671/002.htm

Telugu:
రోగి న్యాయవాది కోసం ప్రశ్నలు;

దయచేసి మీ రోగి యొక్క ప్రస్తుత సమస్యలకు దారితీసిన సంఘటనల క్రమాన్ని వివరించండి. దయచేసి మీ పేషెంట్‌కు ఎటువంటి సమస్యలు లేకపోయినా సంఘటనల క్రమాన్ని ప్రారంభించండి. 

దయచేసి 24 గంటల పాటు మీ రోగి సరిగ్గా ఉన్నప్పుడు అతని గంటా దినచర్యను వివరించండి 

తర్వాత, వ్యాధి అతని జీవితాన్ని పట్టుకున్న తర్వాత, అతని గంటా 24 గంటల దినచర్యకు ఏమి జరిగిందో దయచేసి వివరించండి 

దయచేసి రోగి యొక్క గంట దినచర్యలో ఏ భాగం అంతరాయం కలిగిందో ప్రత్యేకంగా పేర్కొనండి 

రోగికి మన నుండి ప్రస్తుత అవసరాలు ఎలా ఉన్నాయి, మనం అతనికి ఒకే ఔషధం ఇవ్వవలసి వస్తే, వారు ఏ సమస్యను పరిష్కరించడానికి ఇష్టపడతారు?

దయచేసి ఇక్కడ చిత్రంలో క్రింద ప్రదర్శించిన విధంగా ఉదరం మరియు చేయి కండరాల రోగి యొక్క క్లినికల్ ఫోటోను పోస్ట్ చేయండి:

మరియు రోగి యొక్క గుర్తింపును బహిర్గతం చేయకుండా జాగ్రత్తలు తీసుకుంటున్న ఏదైనా ఇతర సమస్యాత్మక శారీరక ప్రాంతం యొక్క ఫోటోను పోస్ట్ చేయండి

PaJR బృందం కోసం టాస్క్:

ప్రాధాన్యతా క్రమంలో రోగి సమస్య జాబితా మరియు గ్రహించిన అవసరాల జాబితాను సిద్ధం చేయండి 

జాబితా చేయబడిన ప్రతి సమస్య అవసరాల కోసం ఒక ప్రణాళికను రూపొందించండి

వారు డైనమిక్ కేస్ రిపోర్ట్ (EHR)ని ఎలా సృష్టించవచ్చనే దాని గురించి ఇక్కడ మరింత సమాచారం: 

https://sites.pitt.edu/~super1/lecture/lec53671/002.htm
Rōgi n'yāyavādi kōsaṁ praśnalu;

dayacēsi mī rōgi yokka prastuta samasyalaku dāritīsina saṅghaṭanala kramānni vivarin̄caṇḍi. Dayacēsi mī pēṣeṇṭ‌ku eṭuvaṇṭi samasyalu lēkapōyinā saṅghaṭanala kramānni prārambhin̄caṇḍi. 

Dayacēsi 24 gaṇṭala pāṭu mī rōgi sariggā unnappuḍu atani gaṇṭā dinacaryanu vivarin̄caṇḍi 

tarvāta, vyādhi atani jīvitānni paṭṭukunna tarvāta, atani gaṇṭā 24 gaṇṭala dinacaryaku ēmi jarigindō dayacēsi vivarin̄caṇḍi 

dayacēsi rōgi yokka gaṇṭa dinacaryalō ē bhāgaṁ antarāyaṁ kaligindō pratyēkaṅgā pērkonaṇḍi 

rōgiki mana nuṇḍi prastuta avasarālu elā unnāyi, manaṁ ataniki okē auṣadhaṁ ivvavalasi vastē, vāru ē samasyanu pariṣkarin̄caḍāniki iṣṭapaḍatāru?

Dayacēsi ikkaḍa citranlō krinda pradarśin̄cina vidhaṅgā udaraṁ mariyu cēyi kaṇḍarāla rōgi yokka klinikal phōṭōnu pōsṭ cēyaṇḍi:

Mariyu rōgi yokka gurtimpunu bahirgataṁ cēyakuṇḍā jāgrattalu tīsukuṇṭunna ēdainā itara samasyātmaka śārīraka prāntaṁ yokka phōṭōnu pōsṭ cēyaṇḍi

PaJR br̥ndaṁ kōsaṁ ṭāsk:

Prādhān'yatā kramanlō rōgi samasya jābitā mariyu grahin̄cina avasarāla jābitānu sid'dhaṁ cēyaṇḍi 

jābitā cēyabaḍina prati samasya avasarāla kōsaṁ oka praṇāḷikanu rūpondin̄caṇḍi

vāru ḍainamik kēs ripōrṭ (EHR)ni elā sr̥ṣṭin̄cavaccanē dāni gurin̄ci ikkaḍa marinta samācāraṁ: 

Https://Sites.Pitt.Edu/~super1/lecture/lec53671/002.Htm

Nepali:

बिरामी अधिवक्ताका लागि प्रश्नहरू;

कृपया तपाईंको बिरामीको घटनाहरूको अनुक्रम वर्णन गर्नुहोस् जसले वर्तमान समस्याहरूको नेतृत्व गर्‍यो। कृपया तपाईंको बिरामीलाई कुनै पनि समस्या नभएको बेलादेखि घटनाहरूको क्रम सुरु गर्नुहोस्। 

कृपया 24 घण्टामा तपाईंको बिरामीको घण्टाको दिनचर्या वर्णन गर्नुहोस् जब ऊ पूर्ण रूपमा ठीक थियो 

अर्को कृपया एक पटक रोगले उसको जीवनमा समाते पछि उनको घण्टाको 24 घण्टाको दिनचर्यामा के भयो वर्णन गर्नुहोस् 

कृपया बिरामीको घण्टाको दिनचर्याको कुन भाग अवरुद्ध भयो भनेर विशेष रूपमा उल्लेख गर्नुहोस् 

हामीबाट बिरामीको हालको आवश्यकताहरू के हो, यदि हामीले उसलाई एउटै औषधि दिनुपर्ने हो भने उनीहरूले कुन समस्यालाई सम्बोधन गर्न रुचाउँछन्?

कृपया पेट र हातको मांसपेशीको बिरामीको क्लिनिकल तस्बिर यहाँ छविमा देखाइएको रूपमा पोस्ट गर्नुहोस्:

र कुनै अन्य समस्याग्रस्त शारीरिक क्षेत्रको फोटो पोस्ट गर्नुहोस् ताकि यसले बिरामीको पहिचान प्रकट गर्दैन।

PaJR टोलीको लागि कार्य:

प्राथमिकताको क्रममा बिरामीको समस्या सूची र कथित आवश्यकताहरूको सूची तयार गर्नुहोस् 

सूचीबद्ध समस्या आवश्यकताहरू मध्ये प्रत्येकको लागि योजना बनाउनुहोस्

तिनीहरूले कसरी डायनामिक केस रिपोर्ट (EHR) सिर्जना गर्न सक्छन् भन्ने बारे थप यहाँ:
https://sites.pitt.edu/~super1/lecture/lec53671/002.htm

[18/05, 19:37] cm: What about the sequential timelined history in your patient?

[18/05, 19:46] +91: Is there an example format for history we can look at?


[18/05, 20:31]cm: Short history (detailed one below this):

1. The patient has tingling and numbness  of lower limbs since 10yrs extending from tip of toes to shin of tibia. 

2. Burning sensation of feet since 5yrs.

3. Chest pain since 4 days, pricking type on and off. No precipitating factors.


4. Loose stools for one day which was one week back and subsided with medication. 

Has Diabetes  on injection Mixtard 20U BBF, 15U BD since 30 years

Had kidney problem since 13yrs.

Known case of  Heart failure 2° to coronary artery disease since one month.

History of stable angina, one month back. 

Detailed history:

An 80- year- old male ,  born and raised in a middle- class family, had a father who practiced as an Ayurvedic doctor, treating people with herbal medications.

He grew up with two elder sisters, one younger sister, and a younger brother.

In his early years, he experienced the tragic loss of his eldest sister to Hansen's disease.

A few years later, his second elder sister passed away after using herbal medications for suspected cancer.

After his father's death from a brain stroke, financial hardships forced him to leave school.

To support his family, he began working in handlooms while attending night school.

The loss of his sisters motivated him to pursue a career in medicine and follow in his father's footsteps.

He got married in 1962.

Later, his younger sister was also diagnosed with Hansen's disease.

After her husband abandoned her, he and his wife took full responsibility for her care until her death.

His younger brother, who was diagnosed with Hansen's disease at the age of six, also passed away eight years ago.

At one point, he purchased a power loom from Bombay and earned a living through it. However, over time, his neighbors also acquired similar looms, leading to increased competition and a decline in customers, which affected his financial stability.

He has four daughters, all of whom are now married.

Fifteen years ago, when his elder sister was diagnosed with diabetes, he decided to get a health check-up. Initially he managed his condition through dietary changes.

A few years later, he began experiencing tingling and numbness in both feet. After consulting at NIMS, he was diagnosed with hypertension, diabetes, and peripheral neuropathy.

Since then, he has been on conservative management.

Full PaJR case report:

https://pajrcasereporter.blogspot.com/2024/10/80m-diabetes-hypertension-30yrs-ckd.html?m=1