THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DEIDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
PAST HISTORY:
The patient is a 29-year-old male. At the age of 7 while climbing a tree to pluck Indian olive, fell down. Minor injuries in the leg which went away on its own after a few days. At the age of 9 again fell down from a tree while playing on a bamboo barrier and cut his thigh region. Used ointment and medication to heal wounds, which healed with time. At age 10-11 while playing hide and sick in a culvert. pushed by a friend and cut both his knees. Stitching was needed for the left knee. Right Knee injury healed with medications. The patient is a toto driver by profession for the past 2 years. Before that patient worked as a gas cylinder delivery boy for the last 8 years. Complaint of headache for the last 9 -10 years especially in the evening. Had decreased after taking Neurola for the past 7 months. For the last 2 - 4 years suffering from insomnia which gradually worsened. 7 - 8 months ago visited a neurologist due to severe insomnia. Took medications Neurola 2mg OD before bed, Questa plus OD before bed, Migrabeta OD before bed. Used to have good sleep after that. The patient is no longer taking Questa and Migrabeta for the past 15-20 days due to financial issues. The patient says that he cannot fall asleep without taking Neurola everyday.4 months ago while driving toto started feeling slight muscle pain in the lower back and thigh region of the left leg, which used to increase while walking. Severe pain for the last 3 months, difficulty in carrying out daily activities. Pain in left leg stretching from the lower back till ankle and in right leg stretching from the lower back till popliteal region. This pain is felt continuously and increases slightly with activity. Sometimes also feel a tingling sensation in left leg, especially while lying down. 1 month ago visited a clinician in a hospital who recommended a tablet for 5 days. The patient was found to be diabetic and have high uric acid. MRI and X-ray were also done. He went to another clinician who gave him 1 tab for 5 days, 1 tab for 20 days, and 1 tab for 3 months. He had stopped taking all medications since 1.4.22 except Neurola. Currently, the patient has been completely bedridden for the last 1.5 months. Cannot visit the washroom without help or support. He worries about money and his job. For the past 1.5 months loose stool 4-5 times/ day. Also, complain of pain in the abdomen (uncovered area as in pic) for the past 15-20 days specifically while sleeping and sitting. For the last 4 years, he is also suffering from erectile dysfunction which had led to stress and anxiety. But he says it is not always. Also, he reported a kind of painful (sometimes burning) sensation while ejaculating and passing urine, which started 4 yrs back and increased from the time he started reporting pain in his lower back and legs.
FAMILY HISTORY:
He is married with 2 kids.
Father - 58 yrs old. Problem old hemorrhoids for the past 30yrs. Did ayurvedic treatment. The problem comes and goes. Diabetes was detected 4 months ago during a health checkup, using medication under control, fluctuating BP no medication.
Mother - 45 yrs old. 9 years ago Sx uterus tumor, 8 yrs ago gallstone Sx. 2 yrs ago fell down and had severe pain. Went to a clinician, L5 dislocation was detected. Cannot sit on floor. Pain increases with work.
Sister - 30 yrs old. Reporting the same leg pain as him but still not severe for the last 15 -20 days.
REPORTS:
Patient's FBS - 104, PP - 218 on 7.3.22 Recommendation - reduce rice intake.
CNS EXAMINATION (12/4/22)
Tones: Rt Lt
U/L N N
L/L N N/decreased
Power:
U/L 5/5 5/5
L/L 5/5 5/5
Reflexes: Biceps Triceps K A Plantar
Rt. 2+ 2+ - - Extensor
Lt. 2+ 2+ - - Extensor
Sensory: Rt Lt
Crude touch
U/L + +
L/L + +
Fine touch
U/L + +
L/L lost decreased
below below
ankle ankle
Vibration: Rt Lt
greater toe 5sec 5sec
ankle 6sec 6sec
knee 9sec 6sec
wrist 8sec 8sec
elbow 11sec 10sec
route 5sec 5sec
of nose
Pain: Rt Lt
U/L + +
L/L lost/deceased lost/decerased
below below
ankle(sole) ankle (on sole)
Joint position: Rt Lt
L/L + +
Romberg's: -ve
Anal tone: +/normal
Saddle anesthesia: sensation intact
Provisional diagnosis:
Lower backache with clinical complexity due to multifactorial drivers
CURRENT MEDICATION:
T. PAN 40 MG PO OD for 15days
T. ETOVA ER 400 MG PO BD 15days
T. TRIGABANTIN 100MG PO OD 15days
DAILY UPDATE:
9/5/22
7:00 am - After walking for 250 mt pain started. Relived on taking rest
10:00 am - after walking for 30 mt pain (comparatively less) started
1:00 pm - while walking stood still for 3 mins pain started
3:00 pm - while standing for 5 mins pain started
6:00 pm - tingling sensation and pain in back and foot sole
In between spending time mostly lying down in bed or sitting on a chair
Diet: 10:00 am - rice, soya bean with kuash sabji
3:00pm - rice, dheki sag, brinjal, raw banana sabji, soya bean kuash sabji
10/5/22
7:00 am - after walking for 200 mt pain started and with a tingling sensation in the feet
12:00 - 1:00 pm - pain started after walking for 50 mt
1:00-2:00 pm - lunch
2:00-4:00pm - lying in bed
4:00-5:00pm - walking
5:00-7:00pm - lying in bed
Diet: 10 am - rice, beans fry, bhindi fry.
11/5/22
9:00 am - While walking pain started after walking for 20 mts
12:00 - 1:00 pm - Pain started after walking for 30 mts
3:00 - 4:00 pm - While sitting pain stretching from the lower back to the knees
5:00 - 6:00 pm - 15 mt walk, after which pain started
7:00 pm - pain in the lower back while standing for 5 mins
In between spending time mostly lying down in bed
Diet: 10:00 am - rice, egg curry, boiled bhindi, dheki saag
13/5/22
9 am - Woke up. Walked for 15 mins. Pain started. Subsided after sitting down for sometime
10 am - slept after eating rice meal
11:00 - 12:00 pm - Spent time sitting idle on a chair
12:00 - 1:00 pm - Walked 30 mt, took 10 mins time. Felt pain
1:00 - 2:00 pm - Walked for 30 mt, took 10 - 15 mins. Felt slight pain
2:00 - 3:00 pm - After having lunch sat on a chair
3:00 - 5:00 pm - Was lying on a bed
5:00 - 6:00 pm - sitting idle without doing any activity. Felt pain in the sole and back of the leg below knee joint
6:00 - 7:00 pm - walked for a few mins, felt a slight pain in the lower back
7:00 8:00 pm - Was lying in bed
Diet: 10:00 am - rice, pat saag, bhindi boiled
14.5.22
8:00 - 9:00 am - Woke up. Walked for 100 mt. Took 30 mins. Felt pain not continuous but with intervals of 2 - 3 mins of no/less pain.
9:00 - 10:00 am - lying down in bed
11:00 - 3:00 pm - sat in his uncle's grocery shop. Felt pain. But still continued sitting.
3:00 - 4:00 pm - bath, lunch
4:00 - 6:00 pm - slept
6:00 - 7:30 pm - sat in his uncle's grocery shop. Felt pain. Returned home walking (felt slight pain) for 5 mins
Diet: 10:00 am - rice, bhindi sabji, mixed veg.
15.5.22
7:00 - 8:00 am - went for a morning walk (100 mt). While walking felt pain which as if got reduced for 2 min. Walked for 30 mins. After that, returned home and was lying in bed.
8:00 - 9:00 am - lying in bed. No pain
9:00 - 10:00 am - after eating rice, sat on a chair (felt pain) idle
10:00 - 3:00 pm - felt pain in the lower back, thigh region, and below the knees while sitting in uncle's shop
3:00 - 3:30 pm - bathing and lunch
3:30 - 6:30 pm - lying in bed. No pain.
16.5.22
7:00 - 8:00 am - Walked for 100 mt. Took 30 min. Felt pain while walking after some time in rt leg
9:00 - 10:00 am - Sitting idle
10:00 - 10:30 am - Ate rice
10:30 - 2:00 pm - Lying in bed
2:00 - 3:00 pm - Sat in shop. Felt slight pain
3:00 - 4:00 pm - Bathing, had lunch
4:00 - 6:00 pm - Slept
6:00 - 6:30 pm - Walked for 30 mt. Felt pain while returning home
Diet: 10:00 am - rice, bhindi fry, karela fry
17.5.22
8:00 am - Went for morning walk for 30 mins. Initially, no pain was felt while walking, but after walking for 10 - 15 mins started to feel severe pain.
9:00 am - Went for blood sugar test. Had to walk for 10 - 15 mins. Felt pain
2:00 pm - Returned home. Bath, lunch. Slept till 6 pm
6:00 pm - Walked for 30 mins to bring back test report. Pain felt after walking for some time, not initially.
NOTE: Patient said while sitting or walking pain is always felt in the whole left leg. No pain is felt in the right leg most of the time. Only occasionally in rt leg.
TEST REPORT - HbA1c - 5.6, FBS - 112 mg/dl, PP - 117 mg/dl
18.5.22
7:00 - 8:00 am - After walking for 30 mt started feeling pain. Needle-like pain in the left hip region. Still walked for 100 mt more. Then was lying in bed till 10 am
10:00 - 10:30 am - Had rice. Then lying in bed till 2 pm
2:00 - 2:30 pm - Had lunch. Then slept till 4 pm
4:00 - 6:00 pm - Walked for 60 mt. After that was sitting on a chair
6:00 - 7:00 pm - Was lying in bed
19.5.22
7 - 8 am - Morning walk for 30 mins. Felt pain. Lying in bed till 10am
10 - 11 am - Ate rice. Sat for 30 mins. Felt pain slightly
11 - 1 pm - Lying in bed
1 - 2 pm - Walked for 10 mins. felt pain. Sat for 30 mins. pain got reduced
2 - 3 pm - Had lunch. then slept till 7 pm. While sleeping felt pain in the sole of left leg
20.5.22
7 - 8 am - went for a morning walk. After walking for 20 - 30 mins started feeling slight pain. Sat down for some time. Then started walking again for 10 - 15 mins
8 - 10 am - Lying in bed
10 am - After eating rice, was lying in bed
11 - 12 pm - Sat on a chair. Felt pain in lower back
12 - 3 pm - Walked for 30 mins. Started feeling pain. So, the rest of the time was lying in bed
3 - 4 pm - Bathing, had lunch
4 - 5 pm - Sat in a chair. Started feeling pain in lower back after 1 hr.
5 - 7 pm - Lying in bed
21.5.22
7 am - Morning walk for 30 mins. Had to sit for 3 mins at 2 intervals each due to pain in the whole left leg and lower back.
8 - 10 am - Lying in bed
10 am - Was lying in bed after eating rice till 12 pm
12 pm - Walked for 2 - 3 mins. Then was standing for 5 - 10 mins. Felt pain. So, was lying in bed till 2 pm
2 - 3 pm - bathing, lunch. After that, slept till 4 pm
4 - 5 pm - was sitting on a chair. Felt pain in lower back and left leg.
5 - 6 pm - walked for 10 - 15 mins. felt pain
6 - 7 pm - Was lying in bed
1 pm - Mango
10:30 pm - khichdi, parwal fry, sabji
22.5.22
7 - 8 am - Walked 80 mt. Took 25 mins. Started feeling pain after walking for 40 mt. So, sat for a while and then walked again.
8 - 10 am - as lying in bed
10 - 11 am - walked for 10 mins. Felt pain below the left knee. Sat for 30 mins. Felt pain while sitting.
11 - 12 pm - slept
2 - 3 pm - After lunch was sitting for 30 - 40 mins. Felt slight pain in lower back
3 - 3:30 pm - walked for 10 - 15 mins. Started feeling pain after walking for 5 mins.
3:30 - 6 pm - was lying in bed
6 - 7 pm - walked 40 mt. Felt pain after walking for 10 mins.
23.5.22
7 - 8 am - First walked for 40 mt but felt no pain. After walking for 120 mt started feeling pain. So, sat for 5 mins. After returning home, was lying in bed. Pain went away after lying for 5 mins.
8 - 10 am - was lying in bed
10 - 11 am - after eating rice, sat till 11 am
11 - 1:30 pm - was lying in bed.
1:30 - 2 pm - after walking for 10 mins, sat for 15 mins
2 pm - lunch
2:30 - 5 pm - slept
5 - 6 pm - while walking for some time felt pain in lower back, below the left knee and sole
6 - 7 pm - felt pain while lying in bed. Felt pain in legs.
10 am - food made with atta and milk
26.2.22
7 -8 am - After walking for 30 mt started feeling pain. Walked for 100 mt then sat and took rest for 5 mins then walked again. Felt numbness and a tingling sensation with pain and heavyness in his legs. After returning home pain went away after lying in bed within 5 mins.
8 - 10 am - Was lying in bed
10 - 11 am - After eating rice, was lying in bed.
11 - 12 pm - Sat in a chair
12 - 1 pm - After walking for 30 mt started feeling pain. A sharp shooting pain that was not going away even on lying down in bed. So, was lying in bed till 3 pm
3 - 4 pm - Bathing, lunch. Then slept till 6 pm. But the pain which started around 1 pm was still continuing in a waxing and waning pattern. Around 6 pm pain went away.
6 - 7:30 pm - After walking for some time, he sat in a chair.
25.2.22
7 -8 am - After walking for 80 mt started feeling a sharp pain in lower back. So, returned home and was lying in bed till 10 am. After eating rice at 10 am, continued lying in bed till 12 pm. But pain reduced insignificantly and was felt all the time. Still, got up from bed at 12 pm and tried waking for some time. Pain increased. So, at 1:30 pm went to lay down in bed and slept till 2:30 pm.
2:30 pm - Lunch. Then slept till 4 pm.
4 - 5 pm - Was sitting in a chair
5 - 7 pm - Was lying in bed. But, felt pain
Diet: 10 am - rice, bhendi fry, papad
26.5.22
7 - 8 am - After walking for 20mt felt pain in lower back and legs. Pt said on other days he could walk for 30-40 mt. But today pain started much early. Still walked for 100mt. Took 40 min. After returning home was lying in bed for 10 mins. At 10 am, after eating rice, was lying in bed till 2pm.
2-3 pm - Bathing, lunch. After that was sitting on a chair till 4 pm. Felt slight pain.
4-7 pm - Was lying in bed.
27.5.22
7-8 am - Walked for 120mt with sitting intervals (2-3 mins each) in between. Took 35 mins. Felt pain after walking for 40 -50mts.
8-9 am - Was sitting in a chair.
9-10 am - Walked for 60mt. Sat for 3min in between. Took 8mins. After walking returned home and sat for the rest of the time till 10am
10-11 am - After eating rice, was lying in bed till 12pm.
12-1 pm - Walked for 30mt. Felt severe pain in lt. leg. Took 5min. After walking, slept till 3pm.
3-4 pm - After lunch was lying in bed. At that time, felt a sharp pain in lower back. The pain lasted for 10min.
5-6 pm - Was lying in bed.
6-7 pm - After walking for some time, was lying in bed.
28.5.22
7-8 am - Walked for 80mt. Felt pain. Today, the pain started just from the time he woke up and continued the whole day. The pain followed a waxing and waning pattern.
8-10am - Felt pain while he was lying in bed in the lower back and lt. leg.
10-11 am - Was lying in bed after eating rice
11-12 pm - While sitting on a chair felt pain in legs and lower back
12-2 pm - Mostly was lying in bed. Sometimes tried walking. Felt pain while walking.
2-3 pm - Bathing, lunch. Then was lying in bed.
3-4 pm - While lying in bed felt a sharp pain in lower back. Was lying in bed till 7pm.
29.5.22
7-8 am Walked for 30 mt. Felt a kind of tingling sensation in legs and heaviness in the legs and thigh region, along with crushing pain. After returning home was lying in bed till 10am. At 10am, after eating rice, was lying in bed. Felt a sharp pain in his legs. From 10:30-2pm was lying in bed.
2-3pm - Bath, lunch. Then walked for 5-10mins.
3-5pm - Slept
5-6pm - Walked for 30mt. Took 5 min time. Felt a tingling kind of pain and heaviness in his legs. After returning home was lying in bed till 7pm.
30.5.22
7-8am - Which walking felt a tingling kind of sensation and heaviness in his legs with a crushing type of pain. Walked for 80mt. Took 25mins. After returning home, was lying in bed.
8-10:30am - While lying in bed felt lower back pain. Woke up. Ate rice and sat on a chair
11-2 pm was lying in bed. Felt pain in the lower back and thigh region
2pm- bathing, lunch. Then slept till 5pm
5-6pm - walked for 30mt. Felt pain and heaviness and tightness in legs as if there is some extra weight hanging from his legs. After returning home was lying in bed.
Diet: 10am - puffed rice.
31.5.22
7-8am - Felt pain while walking. Walked for 100mt. Took 30min. After returning home was lying in bed till 10am
10am - After eating rice, was lying in bed till 3pm. Felt pain in lower back and legs.
3pm - bath, lunch. Then was lying in bed till 6pm.
6-7pm - While walking felt pain
1.6.22
7-8am - Walked for 200 mt. Felt pain, but still kept on walking. Pain followed a waxing and waning pattern. Took 40min to walk. After returning home, was lying in bed till 10am
10am- ate rice, then continued lying in bed till 11am
11-1pm - was lying in bed
1-2:30pm - sometimes sitting while sometimes walking. Felt pain while walking
2:30-3pm - After having lunch slept till 5pm
5-7pm - While walking felt a sharp pain in legs
7-8pm - Was lying in bed.
2.6.22
7-8am - walked for 120mt. After walking for 40 mt started feeling pain. Pain was more intense than other days. Took 30mins. After returning home was lying in bed till 10am.
10am - after eating rice, continued lying in bed till 12pm.
12pm - walked for 10min. Then sat for some time. After that went back to lying in bed till 2pm
2-3pm - bathing, lunch. After lunch slept till 5m
5-6pm - walked for 100mt. Felt a sharp stabbing pain in legs. After that sat for a while. Then walked again for some time. After which was lying in bed.
3.6.22
7-8am - walked for 80mt. Took 20min time. Felt pain in left leg mainly. After returning home, was lying in bed till10am
10am - after eating rice was lying in bed till 11am. Felt pain the whole time along with a tingling sensation in left leg.
11-12pm - walked for 30mt. Felt pain in left leg. Took 3min. After returning home was lying in bed till 3pm.
3-4pm - bathing. After lunch slept till 6pm.
6-7pm - walked for 50mt. The pain started after walking for 50mt. So, returned home and then was lying in bed
4.6.22
7-8am walked for 1km. Took 40min. Felt a sharp stabbing kind of pain. So. walked with sitting intervals in between. After returning home was lying in bed till 10am
10am - after eating rice was sitting on a chair till 11am. Felt pain in lower back.
11-1pm - was lying in bed. Felt slight pain in the leg and lower back.
1-2pm - was walking for sometime
2-3pm - bathing. After lunch, sat for a while.
4-5pm - slept
5-6pm- walked for 60mt. Felt pain. After returning home was sitting on a chair for some time.
6-7pm - was lying in bed.
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