47 years old male with LBA

E-LOGS MEDICINE 


Hi, I am Arefin Sadat, a final-year MBBS student. This is an E-Log that depicts the patient-centred approach to learning medicine. This E-Log has been created after taking consent from the patient and their relatives. The links that were used by me for understanding the available data on the particular disease have been mentioned below in each post. I hope you learn valuable information after giving it a good read.



CASE OF A 47-YEAR-OLD MALE WITH LBA


This is a case of a 47-year-old male who is a businessman in profession. This de-identified blog was created after taking informed consent from the patient.



CHIEF COMPLAINTS

  1. Lower back pain for 7 years
  2. Constipation for 10 years
  3. Gastric acidity and associated right-sided chest pain for 1 year


History of Presenting Illness


The patient was reasonably well till 2016. 

He was used to pulling heavh weigh materials, and one day he got back pain while pulling such heavy weight. 


After that, he started suffering from low back pain, which was occasional. It occurs in an interval of 4/6 months and stays for 2/3 days.

The pain usually occurs while he sneezes, or attempts to sit or tries to stand after long time sitting.


The pain is relieved after 2/3 days spontaneously or by sake of hot water and spray.


In 2018, they consulted with a physiotherapist, who suggested some physical exercise which helped the patient to relieve pain. But he didn’t continue the exercise.


In November 2022, his pain got severe and stayed over 8/9 days. So he consulted with a doctor. His x-ray report suggested spondylitis and a stone in the abdomen. He then did a USG & the USG report confirmed chronic calcific pancreatitis. The doctor suggested an operation for the removal of the stone.



The patient also complains of constipation for almost 10 years. His defecation is not clear and occurs in an interval of 2/3 days generally.

He didn’t consult with any doctor or take medicine regarding the problem.



The patient also complains that he has been suffering from a gastric acidity problem for more than 1 year, which increases after eating rich food and pulse but sometimes occurs even after eating vegetables. He also suffers from right-sided chest pain due to acidity. 

Currently, he is taking the pan-40 tablet for the problem.


He is diagnosed with diabetes, incidentally, just a few days back, while doing other tests.



History of Past Illness


No significant past history.


Family History 


His father was a TB patient.


Patient's Diet 


-Breakfast: roti, tea, puffed rice.

-Lunch: rice, pulse,vegetable

-Dinner: rice, pulse,vegetable


(He eats fish twice a week and meat twice a month)


Personal History  :


Weight - 51 kg

Diet - mainly vegetables(Occasionally fish and meat)

Appetite - Decreased

Bowel- Constipation

Bladder movements - Normal 

Addiction - Smokes for more than 22 years , and takes alcohol for 22 years also.



Clinical Images: 








Clinical Reports: 










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