52 YEARS MALE WITH HYPERTENTION, DIABETES AND LOWER BACK PAIN

CBBLE PaJR participatory learning action research disclaimer

NOTE: THIS IS AN ONLINE E LOGBOOK 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 INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT. Our global community dashboard exists here: https://medicinedepartment.blogspot.com/2022/02/?m=0 and one can join the community through our PaJR volunteers group here: https://chat.whatsapp.com/F84L5SXxj5OAmXus5rpDgU and through our participatory learning action research PLA R group here : https://chat.whatsapp.com/GpmYzMYrXKWH4v0cNuiKaF. More about our community

here : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6163835/ and PaJR here : https://www.researchgate.net/publication/314328348_Patient_Journey_Record_Systems_PaJR_for_Preventing_Ambulatory_Care_Sensitive_Conditions

CHIEF COMPLAINT -

1] Generalized weight loss since 7 years

2] Feeling less energetic since 7 years

3] Facial dullness since 2 years

4] Mid back pain 8 months

5] Tail bone pain 7 months

HISTORY OF PRESENTING ILLNESS -

The patient of apparently asymptomatic 7 years back then he noticed a gradual weight loss which was generalized throughout the body. he also experienced thirstiness, generalized weakness and frequently felt hungry. for this he went to the doctor and got diagnosed with diabetes type 2 for which he was prescribed METFORMIN HCL 1000 mg which he takes usually before breakfast.

8-9 months back he developed lower back pain of the left side which was shooting and radiating type till the hamstring muscles. for this he went to nearby doctor and was prescribed TAB. NEUROKIND ? which he took for about one and a half month. and he got relieved using this medication within 15 days and he completed the course of one and a half month.

6 months back he developed pain in his tailbone which aggravated on prolonged sitting. for this he got advised to use a physio pillow after using which his pain got diminished. but without the use of this pillow or sitting on hard surfaces the pain aggravates.

2 years back the patient and the people around him noticed a marked change in his facial appearance which he describes as facial muscle loss and loose facial skin. this has effected the patients self confidence and his ability to mingle with people as he was always pointed out about how his face had become less attractive and dull. Apart from the above mentioned issues his concentration has decreased in his general office work from past 1 year.

PAST HISTORY -

The patient is a known case of DM TYPE 2 since 7 YEARS for which he takes METFORMIN HCL 1000mg OD

The patient is a known case of HYPERTENTION since 5YEARS for which he takes OLMESARTAN which was of the following doses -

20mg - first 2 years

40mg- next 3 years

20mg -from this march 2023.

The patient got involved in a road traffic accident 7 years back in which he had a patella fracture and muscle tear in his lower mid back which got healed over time. upon general checkup 2 years back the issues were said to be resolved and healed,

No history of any surgeries.

No history of Tb, epilepsy, asthma.

FAMILY HISTORY-

His mother was known case of HTN and passed away last year due to heart stroke. His father died of at the age of 65 from IDIOPATHIC LIVER CIRROHSIS [ no h/o alcohol consumption}

His elder brother has GRADE 2 FATTY LIVER.

PERSONAL HISTORY-

Patient is TAX CONSULTANT by occupation since the year 2002. his profession requires him to sit for about 10-12hrs a day at one place. he lives away from home as his work place is in a different city.

Patient belongs to the upper middle class was married the age of 34YEARS.He has a son [ 16YEARS ]

His son got diagnosed with brain tumor at the age of 3YEARS, surgery was not indicative as the age was a contraindicatory in his case so medications were continued and a minor supportive surgery was performed. At the age of 7YEARS his son was attacked by left facial paralysis after which he was again admitted and in the year 2008 he was operated and the tumor was removed.

in the year 2021 the patients son complained of severe headache and when on the way to the hospital he felt unconscious in the ambulance. Upon examination he was diagnosed with the reoccurrence of the brain tumor and internal bleeding for which he was operated. after the operation took place whole pf his left side got paralyzed which was treated with supportive PHYSIOTHERAPY. Now the patients son is able to move his limbs on the left side but still left with few restrictions in his fingers and wrist.

This scenario of his son's medical issue left the patient both FINANCIALLY and MENTALLY INVESTED. And with time it took a greater toll on his finances and emotional mental status.

Diet - mixed

appetite - normal

Sleep- adequate

bowel - regular but not relieved at once

bladder - normal.

Addictions -

ALCOHOL - NO ADDICTION

CIGARRETTE - 5-6 CIGARRETTES per day since 10 years

DAILY ROUTINE-

Patient wakes up around 6;30 am cleans his room. has chai biscuit and muri prepares food

10am - breakfast goes to work

2-2;30pm - lunch resumes his work