52 YEARS MALE WITH HYPERTENTION, DIABETES AND LOWER BACK PAIN.
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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
5pm - walking for 1 hr and covers a distance around 4kms
consumes black tea after he is back from walk
10pm dinner
12:30 - sleeps.
Date - 10 June 2023
Follow up and prognosis -
This is a update about patients condition after about 17 days of initial case taking.
The patients investigations showed a good improvement. He is showing good prognosis.
During these 17 days the patient was adviced and followed up each and everyday keenly and this has made a marked change in his condition.
Upon interacting with the patient these were the following updates -
1- He is feeling more confident.
2- He seemed to be in a good mood.
3- From past 7 days he is feeling more energetic and lethargy has diminished.
New complaints -
1- Pain in his toes ( explained as pain which usually is seen after playing sports or doing some activity)
His diets medicines which given and follow up reports are furnished below.
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