43 yr old male with gastric problems, insomnia and loin to groin pain

 

PATIENT HISTORY: Pt is a 43 yr old male, a truck driver by profession. Since childhood, he used to suffer from gastric problems on and off. He likes to eat spicy foods. At the age of 20 yrs, he noticed that his gastric problems have increased. He used to feel epigastric pain, a burning sensation in the throat, sour burps, and would vomit sometimes. Because of his work he had to travel outside a lot and had to eat food from hotels and roadside eateries. Also, had to drive the truck till late at night and often went to sleep at 2 am. Sleep was of poor quality. In the morning, after having a meal at 10am he would start feeling bloated. But when he stayed at home and ate home-cooked light food he would be fine. Dr. prescribed medicines that would resolve the issues temporarily. 

10 yrs after continuing like this, at the age of 30 he noticed his gastric problems had changed to - bloating, loss of appetite after one meal in the morning, flatulence, tenesmus, inability to get good sleep, and stool (loose and unformed). He does not feel like eating after having one meal in the morning and in case he still eats lunch and dinner he would feel bloated, and cannot fall asleep. 

8 yrs ago, went to Bihar to deliver goods. While his stay there used to eat a lot of eggs. Previous to the night of driving back to WB, he ate egg curry and rice. In the morning, after walking up he felt lightheadedness, headache, and bloated. While driving he felt very weak, with tenesmus, no appetite, sour burps, and vomited only water. On a friend's advice ate curd which intensified the problems. He parked his truck beside the road and his friends admitted him to a nursing home. Dr. put him on saline and gave him medicine. after staying there for a few hours returned home via bus. Went to a local Dr. who prescribed medicine and he recovered completely in 2 days. He started avoiding eating spicy foods. 5 yrs ago started eating boiled papaya which seems to help his digestion. 

4 yrs ago Dr. advised an endoscopy. Medicine was prescribed but got only temporary relief. When at home, taking rest and on eating home-cooked light food no issues. But, even a small irregularity (during some fesitval/occasion, eating spicy food) causes a reoccurrence of the gastric issues and would temporarily resolve with medicine.

Pt is non-diabetic, non-HTN, high cholesterol detected 4 yrs ago. 

He started smoking at the age of 18 yrs, because of late night work. Smokes 15-20 bidis/day. In between, 4 yrs ago after endoscopy, tried to stop smoking for 4 months. Pt drinks alcohol occasionally. 15 -20 times a year around 150 ml each.

CURRENT CHIEF PROBLEMS  AND PATIENT'S REQ.: 8 months ago, started feeling lower backside pain (mostly while lying down, more common) and on sitting for longer duration pain would migrate to the anterior (flank pain) on both sides. On doing USG, a 0.43 cm renal stone in rt. kidney detected. Dr. prescribed medicine. Temporary relief from pain. Did homeopathy for a few months with no result. Came to Hyderabad for consultation.

Pt. also wants some medication for his digestion issues, tenesmus, and bloating resulting in poor sleep quality.

FAMILY HISTORY: 

Father - had gastric problems (bloating, indigestion, acidity)

Mother - age 78 yrs. Suffering from gastric problems for the past 10-15 yrs(epigastric pain, acidity, burps), HTN for the past 2 yrs.

REPORTS: 

















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