April 14, 2022
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS.
PAST HISTORY: The patient is a 45 yr old male, who is a grocery shop owner by profession.
He heard from his parents that at the age of less than 1 yr, he had an allergic reaction due to an unknown etiology. Had rashes and sneezing. The took him to a village quark and on his advice used to keep him wrapped in banana leaves and fed him some herbal medicine. He recovered within a few months.
In 1992 at the age of 17 yrs, again had an allergic reaction due to an unknown etiology. Had severe rash, ?blisters or lesions on hand and legs with an itchy sensation. Was given an injection in the gluteal region, after which the allergic symptoms subsided.
6-7 months later patient suffered with continuous sneezing and cough with sputum. Went to Vellore where he was recommended to inhale saltwater through his nose. Diagnosis of asthma was made. He was recommended to use an inhaler only if he felt shortness of breath (for the past 18yrs did not use inhaler). His sneezing subsided and he continued coughing with lot of sputum. Clinician prescribed Tab.Tryptomer 10mg OD before bed. The cough did not resolve. So the dosage was increased to 25mg. Taking the same for the past 20yrs.
In between 1.5months ago tried to see what happens if the tablet is not taken on clinician's advice. But the same allergic reaction reoccured. So started the tablet again.
12 yrs ago felt pain in lower back which gradually increased. An X- ray was done. Physiotherapy, a belt for backache and sleep on a hard mattress were recommended. The pain subsided with the following advice. Had to wear belt for 2 months only.
For the past 2-3 yrs suffered from gastric problems (acidity, sour breath, burning sensation in the epigastric region). So severe that he did not want to eat at all. In 2021 July an endoscopy was done revealing a small hiatus hernia in the esophagus and clean based gastric ulcer in prepyloric area. HP kit (Omeprazole+Tinidazole+Amoxycillin) tab taken for 7 days. Gastric problem reduced completely.
4 to 5 years ago onset of slight pain in left knee which aggravated with walking, climbing stairs or straightening folded legs. Gradually pain increased and restricted his movements. Visited the clinician and used to take medicines. The pain got reduced temporarily with medications.
1 yr ago the pain became unbearable. Had difficulty in walking with restriction of movements. Most of the time at home or spent time sitting in a chair while in the shop. Also started complaining of right knee joint pain that was comparatively less, but aggravating during walking and relieving during rest. Diagnosis made at that time.
1. Ch. monoarticular non inflammatory arthritis.
2. Osteoarthritis
3.Medical meniscus tear of left knee.
Medicines and physiotherapy along with a knee cap was recommended.
