57 YEAR OLD MALE PRESENTING WITH BURNING SENSATION ALL OVER THE BODY.


  E LOG GENERAL MEDICINE


Hi, I am Rishitha, 3rd Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING!

 

* This is an ongoing case.I am in the process of updating and editing this ELOG as and when required.

*Elog made with the help of my fellow-mate B.Ajay(3rd sem).



CASE SHEET


57 YEAR OLD MALE PRESENTING WITH BURNING SENSATION ALL OVER THE BODY. 


This is a case of 57 year old male presenting with burning sensation all over the body from past one year.

Chief complaints

  • Burning sensation all over the body from past one year
  • More in peripheral limbs and sole of foot


History of present illness 

  • Patient developed burning sensation one year back. And tried consulting a known intern, who suggested a neuro physician.

  • He also tried seeking help from homeopathy and ayurveda and took their prescribed courses.
Pain history

  • Onset - No trigger, but the burning sensation increases when the patient starts to think or when stress increases. Elaborating, he is a textile shop owner and the burning sensation increases when there are three customers at a time.
  • Character - Continuous but Intermittent increase in the pain. 
  • Radiation - Not always, but the pain radiates to right shoulder intermittently.
  • Time course - The pain starts moderately in afternoon, and gradually increases by afternoon and reaches peak by night before sleeping, causing disturbed sleep.

  • **Exacerbating factor - When under a fan or cooler, there is extreme uneasiness and discomfort from past 10-15 years. And also the patient has a developed a sensation of heat radiating from skin from past one year. 

  • Relieving factor - tablets prescribed by the respective neuro physician he consulted back then, which relieved him from the pain.

  • Pt experiences numbness in extremities on exertion, elaborating, in case like when he is talking on phone for too long or increase in physical stress.

  • The patient had associated burning diarrhoea one year back.

  • Patient experiences burning micturition at times.

  • Patient experiences mild sweating or perspiration.

  • He is myopic and was diagnosed with cataract (stage unknown yet) for which he denied surgery, when told ‘not urgent’ by respective clinician and also experiences pain and tingling sensation in the right eye at times.

  • Patient was diagnosed *positive* for mild case of COVID-19 one and half month back (around May) and was under home isolation.

  • ** during this course of period of isolation (3 days), he did not experience any of the above complaints of the ‘pain history’. He was experiencing ONLY Covid symptoms, such as Ageusia and Anosmia and other covid related symptoms.

  • ** Constant numbness of Right Hallux.

  • Pt also mentions about a thought of having prostate related issues (reason unknown).

  • A dull dragging sensation in the scrotum rarely.


History of past illness

  • Pt is a k/c/o hyperlipidemia (under control)

  • Diagnosed positive for mild case of COVID-19 two months back, after having first dose of vaccine.

  • Not a k/c/o DM, HTN, Thyroid, Asthma, Epilepsy.

  • Sinusitis 10 years back, which relieved on medication.
 Typhoid history 

  • He was Diagnosed with typhoid one year back before he was affected by the presenting complaint.
  • The Typhoid lasted over a month and he had taken homeopathy medication. He used some antibiotics too.
  • When asked about symptoms he mentioned about having fever (upto 101°F) and he couldn’t be more precise after getting a negative Widal test, he resume back to his daily activities and meanwhile lockdown was imposed.
  • He then complained of facing this burning sensation (approx a month after the typhoid treatment).
  • And he had to stay home, merely because of lockdown. Meanwhile he kept consulting different physicians  and took respective prescribed courses.



Family history 
  • Wife is a k/c/o DM

  • Second daughter is a k/c/o Thyroid

Personal History 

  • Occupation - Textile Shop owner

  • Address- Karimnagar, Telangana 

  • Diet - Mixed
  • Apetite - Moderate
  • Bowel - Regular
  • Micturition - Burning micturition at times and a problem of urinary incontinence after returning home, from his work place, where he does not experiences the said problem.
  • Known allergies - Yes. DUST allergy (took medication for three months)

  • Not a k/c/o alcohol abuse or smoking.

  • Sleep pattern - Disturbed.

Treatment History :- Nil


Drug History 

(All these medication were taken by the patient before he was attacked by COVID, that is before May 2021)

  • Tab METHOSAM 200 mg- 1 month
  • Tab PREGABID 82.5 mg - 1 month 
  • Tab NEXITO Fort and Tab NEXITO Ls - 2 months, said this drug helped a lot.
  • Tab MONTELUKAST - 3 months 
  • Tab ATORVASTATIN - 15 years
  • Tab MET XL H25 - 1 week
  • Tab INDEROL 10 mg - 10 days
  • Tab STRESSNIL 0.5 mg - 10 days.
  • Vitamin B5 supplements- 1 month
  • Tab RABILAST
  • Tab PANTAPREZOLE - intermittently from past 20 years
  • Tab RENERVE D - 10 days, then stopped usage because of gas trouble
  • Probiotic Capsules
  • Disodium hydrogen citrate syrup - for typhoid
  • Potassium citrate and Citric acid oral solution.
  • MVT supplements.

  • Ayurvedic courses
After being affected by COVID, he is now ONLY on Ayurvedic Medication. 



Patient  Queries

1. Patient : What must have been the possible cause for these problems?

Doctor: We are yet to diagnose the symptoms, and will reach you as soon as possible.


2. Patient : I think i have some prostate related issues, reason unkown.

Doctor: What made you suspect that problem,sir? Are there any symptoms which you have been facing?

Patient : There are nothing in specific but its just what i felt. Moreover my ayurvedic doctor prescribed me a medication for the same.

Doctor : okay, sir. We would asses the same and reach you as soon as possible.


Provisional Diagnosis 

Neuropathic Pain post febrile illness that in his location could have been an infection due to chikungunya. 


Investigation to be ordered

1. Pharmacological Support

2.Psychological Counselling 


































































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