40 year old male

September 08, 2022

40 year old male

This is a case report of a 40-year-old male who is a professor by occupation

CHIEF COMPLAINTS

The patient complains of

Neck pain from the past 13 months which has increased in severity from the past 18 -20 days
Lower back pain from the past 13 months

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 25 years ago.

25 years ago the patient used to have breathing difficulty, runny nose, and constant sneezing, which was aggravated in the winter months. The patient was treated using homoeopathy medication and the symptoms were resolved within a few years of taking the medication.

2 years ago, the patient was diagnosed with Covid - 19 and was treated for the same. After the recovery, the patient developed wheezing and a runny nose. The patient was given a nasal spray. The patient was also started on BUDAMET Inhaler, which the patient takes 2 times a day since then, in the morning and the evening.

13 Months ago, the patient started experiencing neck pain and lower back pain. . The pain has increased in intensity in the last 18 to 20 days. The patient consulted a neurologist and was advised to do an MRI that depicted spinal cord compression.

The patient has started Physiotherapy for the same, the lower back pain has reduced, while the neck pain persists.

The patient was started on Etoshine 90 and Neugaba M 75

Aggravating factors - Constantly sitting in one position in front of the computer, moving neck towards the left.
Relieving factors -medication
Non-radiating, continuous pain.
There is no associated weakness of the limbs.
Due to the pain, the patient has had to reduce his work.

2 months ago, the patient was teaching a class regularly and he experienced increased sweating and felt physically uncomfortable. The patient visited a doctor and was diagnosed with hypertension. On further evaluation, the tests depicted a raised cholesterol level.

The patient was started on Telista 40 mg, Eslo 2.5 mg and Rozavel 5 mg.

Due to the increased stress from work, the patient had difficulty falling asleep. The patient recollects that he was unable to fall asleep till 1- 1.30 AM and his quality of sleep was disturbed. The patient visited the psychiatrist and was started on medication for three months. The sleep quality has become better and the patient finds it easier to fall asleep.

PAST HISTORY

The patient is a known case of Hypertension, Asthma and allergic rhinitis
The patient is not a known case of DM, TB, Epilepsy, or CHD.
The patient has not undergone any surgeries or blood transfusions.

FAMILY HISTORY

The patient's mother has similar allergic symptoms that exacerbate during the winter.
Father - Spondylytis

PERSONAL HISTORY

Water Intake - 3-3.5 litres a day
Appetite - normal
Diet - mixed
Bowel and bladder movements - normal
No addictions
The patient goes on evening walks every day.
Sleep - after visiting the psychiatrist, the patient falls asleep faster and the quality of sleep has improved.

DRUG HISTORY