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 AVAILABALE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
A 60yr old male aiming to making lifestyle changes rather than take medicine.
July 26, 2022
PATIENT HISTORY: Patient is 60 yr old male who is a government employee by profession, currently posted in the treasury department. Patient was born as a premature baby (8 months). But no issue because of that. When in class 3, age 9 yrs, he suffered from typhoid fever for 10-12 days. Recovery with medicine. Felt weak for a month or so.
When in class 6-7 during the summer holidays, was hit by a ball in the head while playing and experienced severe bleeding from the nose. Later on, experienced bleeding from the nose while ideally sitting at home or in class. His father told that he had some problems and took him to a doctor who diagnosed it to be nasal polyp and prescribed medications and injections. Complete recovery within a few months.
In 1976, when in class 10, suffered from bacillary dysentery (loose stool, with foul smell and blood, 60-65/day, for 4-5 days), extreme weakness, vomiting, and abdomen pain doctor prescribed medicine. Complete recovery within a few weeks.
In 1980, suffered from chickenpox. Had a few episodes of conjunctivitis. The last episode was in 1994. In 2000, while going to work via bus, the bus fell into a pothole. Got a blow in his head. On the next day while attending a funeral felt as if some particle had entered his right eye. The next day while doing office work, suddenly experienced a complete blackout of right eye vision. Went to Chennai to treat his right eye. Doctor told him that his left eye may suffer from the same problem. Normal Sx for right eye and laser Sx for left eye done. Complete restoration of vision. Using glasses now.
In 2010, went to Bhopal for a health checkup. HTN was detected. Doctor prescribed no medicine but recommended lifestyle modification. HTN in control since then.
In 2012 Aug., while accompanying a patient to Hyderabad felt severe pain in the upper right quadrant of his abdomen assumed it to be because of overeating during his train journey. The pain got reduced with medications. In Oct. one day while returning from fishing he experienced unbearable pain in his upper right quadrant of abdomen. Was taken to doctor who recommended a USG. Diagnosis of gallstone was made. After staying on medication (because the surgeon was not available) for 2 months Sx was done. 6-7 months later he started experiencing bloating, abdominal pain with a sudden urge to rush to the washroom for defaecation (loose stool, sometimes with mucus), which was diagnosed as IBS. He took homeopathic treatment which reduced the symptoms to a certain extent. Later, he was treated with allopathic medications. Now, once or twice in a month symptoms reappear, and he takes medicine that time only.
In 2016, he started experiencing left shoulder pain, accompanied a patient to Hyderabad. Diagnosed as frozen shoulder. HbA1c - 6.5%. Doctor recommended exercises and lifestyle changes (stopped sugar, white flour completely, 50% vegetables, 25% rice/roti, rest 25% protein). During his short visit to Hyderabad he reported itching sensation and redness in groin region. Symptoms reduced with Terbinafine ointment within 2 days. Same itchiness occurs for 2-3 times /yr and goes away with the ointment.
Pt. started smoking in 1980 1-2/day due to peer pressure, later 5-6/day. During the lockdown, he was posted in the control room duty where he had to stay alone and work day and night. To battle loneliness and work stress, he started smoking a lot (2packs/day). Presently, 16 cigarettes/day.
Till 1998, he used to work as an executive in printing technology. There, office colleagues and clients used to bring alc. as gifts. He started drinking alcohol occasionally since 1987 (120ml once in 6 months or when friends meet together) while working there.
CURRENT CHIEF PROBLEMS AND PATIENT'S REQ.: 2 months ago started experiencing a sudden attack of tenderness and swelling in the right knee and left big toe joint. Pain and swelling lasted for 2 days. Then reduced significantly on its own. At that time in his office, a free health checkup camp was going on. He consulted an orthopedic about this incident, who recommended tests and made a preliminary diagnosis of gout. His uric acid lvl. was 9mg/dl. He was prescribed medicine but has not taken it yet. Says, will take it if there is another episode of pain. Also, he was 93kg at that moment, so told by doctor to reduce his weight.
Since his retirement is nearing a bit stressed out about where to look for a job after retirement.
Pt. is mentally very strong and more inclined to make lifestyle changes rather than take medicine. Claims to be totally fit with no health issues as such.
FAMILY HISTORY: Father was mentally very strong and did not like to express any health issues. Because of feeling weak, a family member forced him to visit a doctor Blood test revealed low Hb. Because of his stubbornness not to visit Dr. myelodysplastic was diagnosed at a terminal stage. Died at the age of 86 in 2007. He also in his childhood suffered from nasal polyposis.
Mother diagnosed with rectal cancer (bleeding pr while defaecation). Died at the age of 76 for the same.
