55M Dactylitis, Low Backache, Uveitis, Forgetfulness WB PaJR

 

04-04-2025

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.

Patient's Case Diary

 Particular

- Age: 55 years

- Residence: Coochbehar, West Bengal

- Profession: School Teacher

### Symptoms

1. Dizziness: Occasional dizziness for several years, with normal blood pressure (115/80 or 110/75). One instance of high blood pressure (150/90) was controlled through pranayama.

2. Finger and Toe Pain: Pain in fingers and toes, especially at night, for several years. Pain in fingers has become constant over the past two years, with swelling in some fingers.

3. Acid Reflux: Occasional acid reflux and heartburn, with occasional vomiting at night. Symptoms have reduced since eating dinner earlier.

4. Skin Issues: Acne and pimples on the face since age 20, with occasional flare-ups.

5. Eye Issues: Daily eye itching, using Refresh Tears drops. History of uveitis, which was treated.

6. Hemorrhoids: History of hemorrhoids, currently under control with Sitz bath.

7. Back and Nerve Issues: History of back and nerve problems in 2014, treated at AIIMS. Symptoms are managed with exercise.

8. Memory Loss: Gradual decline in memory over several years.

9. Cold and Cough: Occasional cold, cough, and sore throat.

 

### Daily Routine

- 800 ml water intake in the morning on an empty stomach

- One banana after water intake

- Tea and biscuits later

- Lunch at 10 am

- 200 ml water intake at 12 pm and 2 pm

- Light snack at 2 pm

- Dinner at 5 pm

- 200 ml water intake at 6 pm

- Tea at 7 pm

- 200 ml milk intake at 10 pm

[04-04-2025 06.32] PPM 1: The PaJR title here itself may suggest the diagnosis partly other than metabolic syn that he has.

[07-04-2025 12.51] PPM 1: Reviewing in OPD

[08-04-2025 11.21] PPM 1: @PPM 3 @PPM 4 what is the grade of spondyloarthropathy if any in this x-ray?

[08-04-2025 13.13] PPM 4: Sir, the sacroiliac joint space is narrowed on both sides, which is bilateral grade 3 according to the New York Criteria (Grade 3: unequivocal abnormality - moderate or advanced sacroiliitis with one or more of: erosions, evidence of sclerosis, widening or narrowing of joint space, or partial ankylosis)

PPM 1: 👏