65 SUCHITHA KOLA. 45yr old patient with pain from loin to toes

45 old male patient with pain from loin to toes

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

           CASE REPORT:-

A 45 old male patient who was born on 10 th Feb 1973 who is a waiter by occupation presented to the OPD with the 

CHIEF COMPLAINTS:-

Bloating in stomach in the morning since 7 years .

Burning micturition since 5 years. 

Pain from loin to toes from past 7 months. 

HISTORY OF PRESENT ILLNESS:-

He was apparently asymptomatic 7 years back 

Then he developed bloating in the stomach which gradually decreased as the day progresses.No aggravating and relieving factors.

Bloating did not relieved on defecation.There was no history of constipation, diarrhoea, fever , nausea and vomiting. Then he went to local hospital where he was prescribed with medication ( indication unknown, drug unknown, dose unknown) but it did not relieve on medication. 

Then after 2 years he started having buring micturition with dribbling of urine. Not associated with pain , hematuria, oligouria, edema . He did not consult a doctor and was not under any medication .

Since 7 months JAN 2022 , He developed lower back ache which radiated to the toes and shoulder to finger tips pain. Which is gradual in onset progressive in nature, continous ,pricking type of pain which did not relieve on medication and aggravated on sitting and standing.He also complained of numbness and tingling. 

In March 2022 , he went to hospital where regular investigations are done including MRI where some medication are prescribed but the pain did not relieved.

Now in AUG 2022 Now he came to our hospital for the further evaluation.

PAST HISTORY:-

not a known case of DM, HTN, epilepsy, CAD, asthma, TB, leprosy

PERSONAL HISTORY:-

appetite - decreased 

diet - mixed

bowel and bladder - regular

sleep adequate - adequate

addictions - SMOKING - 20 PACK YEARS

NO ALCOHOL CONSUMPTION. 

FAMILY HISTORY:-

MOTHER HAVE SIMILAR COMPLAINTS IN HAND WHICH RELIEVED ON HOMEOPATHY MEDICINE. 

Allergic history:- 

not allergic to any kind of drugs or food.

Daily routine:-

GENERAL EXAMINATION:-

The patient is conscious co-operative and well oriented towards time place and person.

well built and well nourished

VITALS:-

temperature:-Afebrile

pulse rate:- 82 bpm

respiratory rate:-16 CPM

B.P:-120/80 mm Hg

SPO 2 :- 98 %

GRBS :- 102 mg/dl

No PALLOR  

No icterus 

No cyanosis 

No clubbing

No lymphadenopathy

No oedema

SYSTEMIC EXAMINATION:-

CARDIO VASCULAR SYSTEM:-

S1 and S2 heard 

No Murmurs heard

Per abdomen:-

the shape of the abdomen:- Scaphoid

no tenderness

no palpable organs

bowel sounds - present

RESPIRATORY SYSTEM:-

Bilateral air way entry - present

Normal vesicular breath sounds are heard all over the chest

CENTRAL NERVOUS SYSTEM:-

The patient is conscious. 

No focal deformities. 

Signs of meningeal irritation:- 

NEGATIVE

cranial nerves - intact 

sensory system - intact

motor system - intact

INVESTIGATIONS done before coming to our hospital:-

PRESENT INVESTIGATIONS:-

Cross consultation:-

Radiological investigations:-

DIAGNOSIS:-

LUMBAR SPONDYLOPATHY?? 

Urinary incontinence under evaluation??? 

TREATMENT:-

 Tab. NAPROMYCIN 250 mg BD

Tab Pan 40mg

Tab pregabalin 75 mg BD