GENERAL MEDICINE E-LOG

A 31 YEAR OLD MALE WITH EXCESSIVE SNEEZING

This is an online E log book 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 series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

 This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment .

ARUSHI KUMARI
151

A 31 year old male came to the ward with chief complain of 
- excessive sneezing since 2011 
- excessive snoring since last 1 month 

HOPI
* A 31 year old male presented to the ward with chief complain of sneezing since 2011 .
- He complains that discharge during sneezing episodes comes only from left nose which usually last for about 1-1.5 hours and it always resolved by taking medication MONTINA - L 
- sometimes though rarely he used to get releived by taking coffee 
- Sneezing episode is associated with ringing sensation and decreased hearing  in the left ear 
* History of excessive snoring since 1 month 

Past history : 
1. History of left ear tympanoplasty  twice 
Once in the year 2011 and then again in the year 2016 .
- He got operated in some hospital in Karnataka for the same .
2. History of hemorrhoid surgery in the year 2018 .
He was experiencing difficulty in passing stool since 2011 .
- Also he used to notice blood in stool ocassionally and some sticky discharge in stool .
So finally he was operated for the same in 2018 .

 Personal history : 
- Mixed diet ( consumes more non veg ) 
- inadequate bowel and bladder movement
- patient complain that difficulty in passing stool still did not resolved after operation .
- Ocassional alcoholic ( twice monthly) 
- chronic smoker since 10 years ( 3-4 cigarette per day )
  
** Patient also complain that he gets irritated very frequently when his customers keep asking the same question again and again because of which he gets so much angry and is loosing interest in his job .
- sleep adequate 
- Appetite normal
- also complain of tension due to work related issues 
- patient himself is agreeing that he is short tempered and gets angry  easily and is not able to control his anger 
- complain of snoring at night for which he is feeling bad as his 4 month old child is getting disturbed while sleeping 
- history of frightfullness
- he gets afraid on seeing down from 3rd or 4th floor or on the sight of giant wheel .

Allergic history : 
* History of allergy since 2016 ( may be after is 2nd ear surgery ).
He used to get lesion in both right and left upper limb , back of neck and below shoulder  ( in scapular region ) .
- The patient describe the lesion as :
* It start as one small black spot then many large , black pustules surrounds it ( ??pruritic psoriasis ???) 
* Since 2 months these lesions has increased .
He gets in every 6 month and one episode last for 1-2 month .
* He is using one ointment for this named  "Derolin" .
He use this ointment whenever he get this skin problem but it used to take very long time to subside ( as said by patient ) .

REPORT

         Ultrasound report 18/12/21 


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