Thursday 21 April 2022

Medicine Case

A 36 yr old male came with Complaints of  upper backache since 9 months. 

C/o B/L shoulder pain since 9 months

Patient was appatently asymptomatic 9 months back and then he developed upper back ache and bilateral shoulder pain associated with cramping (on&off) after moving heavy objects. Patient is very conscious while swallowing of food and feels discomfort in throat.
Indigestion + 
Belching f/b chest discomfort.

The patient studied till 9th standard in his village and went to Guwahati, Assam for working as a day labourer in the construction field in 2001/02 at the age of 17. He used to have alcohol from the age of 17 but the quantity consumed was less. He spent 2 to 3 years in guahati and then went to Shillong, Meghalaya to work in the same construction field but he was getting more money compared to Guwahati. In 2003, he was getting work as an independent contractor and was earning around 25,000 rupees of disposable income. During this time, his alcohol intake has increased considerably to around 375 ml per day and he used to smoke a pack of cigarettes a day till the start of covid period during the end of 2019. For Almost 15 years he was drinking alcohol and smoking incessantly. 


In 2010, he had septoplasty with Grommet insertion in left ear


By 2012-13, he had savings of around 10-12 lakhs and he wanted to build a house with the money he had but due to his father illness who had issues with his liver, the patient had to spend around 5 lakhs on the treatment of his father. His father had passed away in 2014. Just before his father passing away, on the insistence of his relatives he got married in the end of 2013. He again went back to shillong for the work as usual.


2016, he got the house constructed where his family(himself, wife and two kids aged 7 and 2) has stayed since then. His 2 brothers stay at the house built by the patient’s parents. 


During the construction of the house, the patient wanted to build a small temple in the premises of his house but he could not complete it due to lack of money. This is one of the important factor in the history of the patient.


In around 2018 he was having pain in the lower abdominal region which was later detected as hernia after making visits to atleast three hospitals. Ultimately he got operated for hernia. One significant point about the pain in the abdominal region before detecting as hernia was that the patient went to a priest asking for advice for his abdominal pain and the priest directed and highlighted the fact that the INCOMPLETE TEMPLE has to be completed if his problems with health have to be solved. The patient has a strong inclination that the incomplete temple in his house is having some impact on his health and also he fears that this factor might negatively affect his children and his family also. 


After the start of Covid from the beginning of the year 2020, he stayed in his village in north Bengal and he could not go to shillong which was his work place since almost 15 years. He was doing heavy physical work in shillong but in his village he started to live a sedentary life. He had started a small grocery store and he says he is earning less than half the amount which he used to earn in shillong. 


Since the time of start of covid, his alcohol and smoking habits have also decreased and he now says he drinks alcohol in very meagre amounts that too once in a month or two. He stopped smoking now since almost 2 years. 


Since one year he is having issues with pain in upper back, bilateral shoulder pain associated with cramping (on&off) after moving heavy objects. He is having discomfort while swallowing food, formation of gas in stomach. These issues seems to have started after he became sedentary after 20 years of hard physical labour work. 


Not a K/C/O DM, HTN, TB, Asthma, Epilepsy

H/o septoplasty with Grommet insertion in left ear 12 yrs back
H/o appendectomy 3 yrs back

Appetite - Normal
Diet - Mixed
Sleep - Adequate
Bowel and bladder movements - Regular 

Alcohol - occasional ( previously regular )
Habit of tobacco chewing +

O/E :
Pt is c/c/c
Temp - Afebrile
BP - 110/80 mmHg
PR - 79 bpm
CVS - S1S2 +, no murmurs
RS - BAE +, clear
P/A - Soft, NT
CNS - NAD

ENT Opinion - 
Left EAR : TM Intact & Retracted
                    Cone of light absent
Laryngoscopy done :




Provisional diagnosis - 
? Laryngeal Pharyngeal Reflux

Treatment :
1) TAB PAN 40mg PO/OD
2) OTRIVIN nasal drops TID
3) Steam inhalation 3 times/day 
4) Elevation of head
5) Eat 3 hours before sleep
6) Avoid throat clearing
7) Physiotherapy for upper back

Reflux Symptom Index

          Symptoms
0 = no problem
5 = severe problem
1. Hoarseness or a problem with your voice012345
2. Clearing your throat012345
3. Excess throat mucus or postnasal drip012345
4. Difficulty swallowing food, liquids, or pills012345
5. Coughing after you ate or after lying down012345
6. Breathing difficulties or choking episodes012345
7. Troublesome or annoying cough012345
8. Sensation of something sticking in your throat or a lump in your throat012345
9. Heartburn, chest pain, indigestion, or stomach acid coming up012345
RSI > 13 = AbnormalTotal

RSI - 26



Reflux Finding Score
Subglottic edema0 = absent
2 = present
Ventricular2 = partial
4 = complete
Erythema/hyperemia2 = arytenoids only
4 = diffuse
Vocal fold edema1 = mild
2 = moderate
3 = severe
4 = polypoid
Diffuse laryngeal edema1 = mild
2 = moderate
3 = severe
4 = obstructing
Posterior commissure hypertrophy1 = mild
2 = moderate
3 = severe
4 = obstructing
Granuloma/granulation tissue0 = absent
2 = present
Thick endolaryngeal mucus0 = absent
2 = present
RFS - 0

26/04/22

Ophthal Opinion - 

C/o burning sensation in both eyes since 6 months 
With redness and swelling over lower lid of both eyes 

V/A : 
Right eye - 6/36 . 6/12
Left eye - 6/36 . 6/12

Refraction : BE 2.00 Dsph 6/6 

O/E : 
                           Right eye                      Left eye

Lids          Small pustule over          Small pustule over           
                      lower lid                          lower lid
Conjuctiva      quiet                        Small cyst over lower       
                                                        palpebral conjuctiva

Advise given - 
Regular spectacle use
Eye ointment ciplox BD
LID Hygiene
Hot fermentation
Eye drops Lubrex 4 times/ day for 5 days
TAB TAXIM O 200 mg BD x 5 days


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