51 yr old male with fluctuating BP, dizziness

 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 51 yr old male, who owns a printing press business.

16 yrs ago, while on a routine checkup, HTN was detected. He started using Homeopathic medicines, which kept his BP under control. 

For the past 16 yrs, he c/o a sudden severe headache once a month, mostly during the summer months. At that time, pt needs to abandon whatever he is doing and go to sleep. After sleeping headache goes away. Sometimes need to take Dart tab.

In 2019, while on a routine checkup, his Dr. friend advised him to start Tellzy Ach 40/5/12.5 o.d. 

In 2021, on a certain occasion, he ate quite a lot of eggs, chips, and salted cashew for a few subsequent days. One day after waking up from sleep and starting his daily routine activities, he felt a bit dizzy and c/o of no appetite and malaise. His BP turned out to be high and Dr. advised him to reduce the salt intake and prescribed Telma 40 b.d. A few days later his Bp was reduced to 105/70. Dr. reduced the dosage to o.d. After which he had no complaint.

Once while accompanying his close associate to a nursing home, a nurse hearing about pt's condition advised him to take Telma AM o.d instead of Telma 40. He started taking Telmikind AM o.d.

For the past 4 yrs, he is c/o constipation with increasing severity. No defecation at all if not taking Ayurvedic medication or Sorbiline (Tricholine citrate and sorbitol) or incomplete evacuation, leading to abd bloating, borborygmi. 

In 2019, after his father passed away, he became emotionally disturbed and is under stress thinking about his mom who is staying alone, and other family issues. He started drinking alcohol and is still continuing.

For the past 3 yrs, on consuming milk c/o borborygmi, sometimes abd. bloated. 

For the past 1 yr c/o, keep pain while climbing stairs. Under homeopathy treatment.

For the past few months, c/o a feeling of something stuck in the throat (globus pharyngeus). Resolved with homeopathy medicines. Also c/o fishy or sour burps long after eating fish curry (no complaint if only fish is eaten without curry and masala).

For the past 1 wk, he noticed his BP to be 125-130/84-82 mmHg in the morning, but sometimes in the evening, it increases to 150/100 mmHg and sometimes his ears/face turn red/flush. Also, c/o dizziness (3-4 times past 1 wk) while turning his head swiftly from side to side.

ADDICTION: Pt denied smoking. Since the age of 35 started consuming alcohol (180-240 ml) on occasions. After father's death, during covid lockdown because of emotional disturbance and stress, started consuming regularly with friends. 180-240ml every day to date.

CHIEF COMPLAINT AND Pt. REQ.: 1) HTN for past 16 yrs, fluctuating since past 1 wk with c/o dizziness, face flushing

2) Constipation for the past 4 yrs

3) Headache once a month, for the past 16 yrs

4) Knee jt pain while climbing stairs for the past 1 yr

5) for the past few months c/o acidity, abd bloating, borborygmi 1-2 / month









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