CASE OF A 38/M PATIENT

Hello! This is Likhita.M

This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians singned informed consent. Here we discuss our individual patients problems with an aim to solve the patient’s clinical problem with collective current best evident based input.

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This is a telemedical case report of our patient.

ALL THE HISTORY WAS TAKEN AS A TELEPHONIC CONVERSATION

A 38 year old male, resident of a West Bengal who is an assistant professor by occupation has reached out to the hospital with

CHIEF COMPLAINTS OF

- Pain in both the legs since 3 years

Whose severity increased since 2 years

- Lower backache since 2 years

- tingling sensation in his limbs since 1 year

HISTORY OF PRESENTING ILLNESS

- Apparently the patient was asymptomatic 3 years ago when he developed pain in his lower Limbs , which was insidious in onset, gradually progressing since 3 years to what it is now.

The patient describe the pain to be of dragging type from below the knee joint to above the ankle joint and mostly in the calf muscles and no migration of pain.

The pain seems to be aggravating on standing, lifting heavy weights and walking and relieves on rest.

The patient apparently used painkillers as prescribed by his physician for his knee pain 2 months (October and November) in 2021 (2 yrs back) and stopped using them thereafter.

- The patient also complaints of having pain in the lower back region while sitting down in front of the computer for a Prolonged time which he described to be of dull and diffused type.

- He then developed tingling sensation in his limbs 1 year ago.

NEGATIVE HISTORY

The patient didn't seem to have any of the following ;

Fever,

Swelling over the joint, Warmth, stiffness and redness over the joint

No decreased range of motion, joint deformities, fracture, locking, weakness and wasting , instability, rash, fatigue or sleep disturbance.

PAST HISTORY

He is a K/C/O

Hypertension since 2017

For which has been using TELMISARTAN 40 mg

N/K/C/O diabetes , epilepsy asthma, CAD, TB

FAMILY HISTORY

- His FATHER is a known case of h/t and osteoarthritis along with some kidney issues

- His MOTHER is a known case of h/t

- His SISTER is a known case of arthritis (currently taking treatment for it)

PERSONAL HISTORY

Height - 5 foot 3 inches

Weight - in a range of 60-70 ( patient is not sure)

Diet - mixed type

Addictions - none

Regular bowel and bladder movements

Adequate sleep

THERE WERE NO MAJOR LIFESTYLE CHANGES

DAILY FOOD CONSUMPTION

Sunday:

Breakfast: Luchi or paratha and Alu sabji and Tea.

Lunch: Rice, Fish, seasonal vegetables

Sour Curd or fruits ( papaya/ guava/ apple)

Tiffin: Muri and Tea

Dinner: Rice and Roti both and vegetables.

Monday:
Breakfast: Roti and sabji and Tea

Lunch: Rice, Fish, seasonal vegetables

Sour Curd after lunch

Tiffin: Muri and Tea

Dinner: Rice and Roti both and vegetables.

Tuesday:

Breakfast: Roti and Sabji and Tea

Lunch: Rice, Dal, vaji, seasonal vegetables

Tiffin: Roti and Tea

Dinner: Rice and Roti both and vegetables.

Wednesday:

Breakfast: Maggi with vegetables or egg. Tea

Lunch: Rice, Fish, vaji and seasonal vegetables.

Sour Curd after lunch

Tiffin: Muri and Tea

Dinner: Rice and Roti both and Chicken.

Thursday:

Breakfast: Roti and sabji and Tea

Lunch: Rice, Fish, seasonal vegetables.

Tiffin: Tea and biscuits.

Dinner: Rice and Roti both, dal and vegetables.

Friday:

Breakfast: Tea with biscuits and Dalia

Lunch: Rice, Fish, seasonal vegetables.

Tiffin: Bread toast and tea.

Dinner: Roti and chicken.

Saturday:

Breakfast: Roti and sabji. Tea

Lunch: Rice, Dal, vaji and seasonal vegetables.
Fruits after lunch.

Tiffin: Bread toast and tea.

Dinner: Rice and Roti both and panner sabji.