A 40 yr old male with HTN, elevated triglycerides and hyperuricemia

August 17, 2022

NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

PATIENT HISTORY: Pt. is a 40 yr old male who is a professor by profession.

From age 14-18 yrs, he used to fall ill often with cough and cold accompanied by headaches, sputum, and runny nose, especially during the winter. These symptoms occurred till class 11. Homeopathy treatment was done, which ultimately resolved all the symptoms by the time he turned 18.

During college, he would study late at night and often skip food due to study pressure. He c/o acidity, after meal frequent sour burps, epigastric pain, no appetite, feel bloated. So, used to take a lot of antacids on his own accord. After becoming a school teacher his gastric problems increased because of work-related stress and skipping meals. Finally, in 2009 he went to Hyd. Dr. prescribed medicines and by 2018 all his gastric problems got cured.

In 2015 joined University and in 2018 got promoted. After his promotion workload increased drastically, making him unable to timely eat proper food and had to return home late at night. In 2021, he resigned from his post because of his excessive workload.

In 2017, he started c/o continuous sneezing after waking up in the morning, runny nose, watery red eyes, and wheezing breath sound. Dr. diagnosed symptoms to be due to dust allergy and prescribed Budamate 200 inhaler and Fluticon FT nasal spray. With these medications, he got relief and still continued using them as prescribed.

In 2020, fell sick with Covid. After recovering from covid in May, he again started c/o wheezing breath sound during sleep at night along with SOB. Dr. increased the dosage of Budamate and also prescribed Montair 10 for 10 days. Within 2-3 months his symptoms resolved.

In 2020 Dec, his workload further increased and he started c/o tiredness and mental fatigue. He used to go to sleep around 12-12:30am and wake up around 5-5:3am using an alarm because of his workload. His sleep would be incomplete. Tests detected HTN (he normally would have pressure on the lower side), elevated triglycerides (so taking Rozavel 5), and hyperuricemia (so taking Febustat 20). After a few months when his BP became normal, Dr. tried reducing the dosage. One day while in college at around 5 pm, he started sweating profusely and felt dizzy. Rushed to Dr. who told him that his BP has increased and increased dosage to Telista 40. BP is back to normal with medication. Dr. also recommended a psychiatrist to check whether his BP fluctuation is due to psychological issues/stress. The Psychiatrist said he is alright except for his lack of sleep and work-related stress. Prescribed Evion LC and Panazep LS (still continuing), taking which he feels very calm and cool. He now sleeps from 10:30pm to 7 am.

For the past 1 yr c/o cervical pain with lower back pain. Cervical pain has increased in intensity for the past 1 month.

After detection of HTN and high cholesterol. he started going for walks and doing freehand exercise for 1 hr daily. He eats home-cooked light food.

He is nondiabetic. Does not smoke and has no addiction.

CURRENT CHIEF PROBLEMS AND PATIENT'S REQ.: He wants a second opinion and is concerned a bit since he had to take so many medicines at only age 40.

Because of Panazep 12.5, he is sleeping more, which makes it difficult to finish his preparations before taking the class.

He is suffering from neck pain for 8 to 10 days. In the daytime it is mild but at night the intensity increases. He consulted with the doctor who suggested he do an MRI of the cervical spine.

PATIENT REQ. PRIORITY WISE:

1) Pt is c/o fluctuating BP (even while on medications; possible etiology as suspected by pt - work-related stress)

2) Elevated triglycerides (currently on medication Rozavel 5, supposed to do lipid profile test next month)

3) Neck pain (intensified in past 2-3 wks) and lower back pain

4) c/o wheezing breath sound during sleep at night along with SOB (using Budamate inhaler gives relief)