62 yrs old male w/c/o SOB, lower back pain

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 62 yrs old male, a forest ranger (retired)

Pt belonged to a very humble family and lived in a village during his childhood days.

At the age of 15-16 yrs, used to c/o indigestion, acidity, and epigastric burning sensation sometimes. Dr. prescribed medication, which provided relief. 

Around the same age, one day while passing stool in an open field, he noticed his stool color is black. After defecation, he stood up to fetch water and felt lightheadedness and as if he will faint. He was falling, but his friend caught him in the nick of time.

In 2002, suffered from malignant malaria (first admitted in hospital for 15 days, then again 15 days, and again 7 days within a year)

After getting the job (age 37), when posted in Purulia, he c/o abd bloating, and sore throat, one incident of passing tarry stool  Dr. did USG (report lost) and up. GI endoscopy ( Dr told some issue with the intestine {?bleeding ulcers}, reports lost). Medications prescribed, completed course, no more complaints after that.

At the age of 48 yrs (2009), when posted in Siliguri, once during a raid, he arrested two poachers. The incident agitated him a lot and he even beat them up. At night around 3 am, He woke up from sleep with a complaint of SOB. After sitting for a while he felt alright, so again tired to go back to sleep. 

At around 4 am, he woke up again, to pass urine. While walking back to bed, he felt dizzy and lightheaded. Lost consciousness (1.5 HRS). He immediately got admitted to a local hospital. They referred him to another hospital where he stayed for 10-15 days. 

Went to Bangalore, where a coronary artery blockage was detected. PTCA via radial art. was recommended but needed to be delayed (a recent wound from radial art cannulation during a previous hospital stay not healed up properly). Medications were prescribed for 6 months. 

In 2011 (aged 50 yrs), went to Bangalore, and PTCA was done. He was feeling alright, but after 6 months started c/o pin and needle/itchy sensation starting at the right side of his back, 2-3 cm lateral from the thoracic vertebra, medial to the medial border of the shoulder blade (pic attached). Then the pain would radiate to the lower back and the shoulders.

In 2015 (aged 54 yrs), during Diwali, he did all the arrangements for his society. Had to ride a bike for a long time that day. Next day, severe pain in the lower back. Complete bed rest took analgesics. After 2 days recovered. 

Since then, every 1.5-2 months later, he c/o lower back pain? lasting for 2-3 days, especially during winter months, reduce with analgesic creams.

In 2015-16, again c/o SOB, malaise, and lack of sleep. SOB was mainly on climbing to the 4th floor. Went to Bangalore, Dr did an angiogram and said the stent is in rt place and all reports are okay. 

Pt denied any h/o HTN, DM

ADDICTION: Smoking started during college days, first 2-3 bidis occasionally (peer pressure), then cigarettes 3-4/day (not able to find a job), Increased it to 1-2 packs/day (overjoyed because of promotion) aged 39 yrs (2001-02). After CAD was detected, reduced it to 1/day. Then stopped altogether in 2012.

Alcohol - started in 2001, when posted to Siliguri because of colleagues. Had to do patrolling the whole day and night. Used to drink 300-400 ml/day. In 2019-20, after c/o SOB, reduced it to 60 ml once in 2-3 days.

Chewing tobacco - started with friends in 2001, 50 gms packet last for 3-4 days, take 4-5 times/daily. Tried to give up, and threw away the packet once in 2012-13, for a few days only, but experienced withdrawal syndromes. So, continues to date.

CHIEF COMPLAINTS AND PT REQ: 

1) while climbing stairs or tying shoelaces c/o SOB. But can walk for 3.5 km in 30-40 mins without any problem.

2) sometimes c/o a pin and needle/itchy sensation in the back radiating to the shoulder and lower back

3) lower back pain happening once or twice in 1.5-2 months since past 10-12 yrs

4) CAB detected and PTCA was done in 2011, wants further advice

FAMILY HISTORY: 

Grandmother (mom's side) - died due to oral Ca

Mother - 86 yrs old, c/o lower back pain

Father - chr alcoholic (destroyed all money on alcohol), gastric ulcer, died at age of 64 yrs

Brothers and sisters - claim to be fit and fine

COMMENT:  During history taking, Pt was very polite, and cooperative and followed all instructions. Pt claims to be hot-tempered.

REPORTS: