This medical history is composed and compiled in the following manner:
“A covering letter” followed by “Medical history” plus “Summary of Investigations” and
A folder comprising of the scan-files (.jpg files) of the actual Radiographs, MRI’s, Laboratory investigations, SSEP & EMG and their respective outcomes reported.
The medical history file and this covering letter are being posted to you for your perusal in the first place. However, in order to derive an un-influenced opinion, you may log onto the Internet and take a visit to the hyper-linked address to study the second part and make observations.
In this regard your valued and highly sought out opinion and the follow-up advice is humbly requested.
Thanking you in anticipation and obliged.
Yours truly,
Kamal Raza.
B-128, Block # 10, Federal ‘B’ Area,
Karachi-75950,
E-mail: [email protected]
HISTORY
INITIALS:
Syed Kamal Raza,
aged 40 years, a doctor by profession is an unmarried Muslim person and is the
resident of B-128/10,F.B. Area,
PRESENTING COMPLAINT:
Restricted, imbalanced bodily movements of his right side, especially of the upper and lower limbs _____ since May 2000.
Exhaustion and pain in nape and shoulders, difficulty in holding of neck _____ Associated with the first symptom.
Palpitation ____ an infrequent parallel symptom.
Shallow breathing ____ as above.
HISTORY OF PRESENTING COMPLAINT:
According to the patient, he was perfectly all right back in 1998. One day when he had to sign and countersign his name for a bank transaction, he suddenly noticed this slight weakness in his right hand only. He experienced no any other symptoms as of pain etc. Since year 1998, the complaint itself has remained to be of the same intensity with which it began. There was no sensory loss but motor slowing in the affected limb.
Back in year 1999,the patient had to follow an emergency task on a big thesis, which took him under severe work stress. This initiated his cervical complaints of pain, uneasiness and stiffness.
He was deputed as a lecturer at PNS HIMALYA, in March 2000.Only after the second month; he developed symptoms of over-stresses with stiffness in right lower limb and imbalanced gait. By the end of June, he had approached his present status of complaints, which made him to quit his job. Yet during the following of his drug therapy, he did notice intermittent relief in stress and then sudden increase with no evident cause for it.
As for his treatments, a short time after he first showed with his symptoms, he resorted to a homoeopathic practitioner who considered this as a dehydration problem, and treated him for 3/4 months. He continued with his treatment till he developed his cervical complaints due to some work stress as aforementioned. He saw a physiotherapist for the complaint and was given ice therapy treatment with heavy jerks to neck, which only aggravated his problems.
He was prescribed sedatives but nothing helped. It only grew more anxiety alongwith initiating gastric complaints of mouth ulcers. He had also been prescribed on antidepressants, antiparkinsonic drugs in the following of some reflex tests. During the course of his treatment, he was referred to several neurologists. Some regular investigations include; Brain MRI, Fundoscopy for KF ring test, Serum Cerulloplasmin, Serum Copper, Urine Cu, SSEP and EMG. All came out to be clear and with normal physiology.
PAST HISTORY:
MEDICAL:
1985__He was
given Dramamine during fever due to which Tetanic
symptoms developed until treated.
1986__Received few small but deep cuts on the dorsum of his right forearm.
1991__He suffered a great
electric shock caused by direct hit from a hanging wire of transformer.
1996 _ In the month of July, on his way back home, the patient had to carry a very heavy load on his right shoulder across a distance of 2 – 3 kilometers. He did feel badly exhausted after the episode.
SURGICAL:
1983__Operated for SINUSITIS.
PERSONAL HISTORY:
SLEEP__Not disturbed usually.
Appetite__Normal.
MICTURITION__Urgency occasionally, otherwise normal frequency
1½_2litres/day.
BOWEL__Normal.
ADDICTION__ Nil.
WEIGHT__Normal.
DRUG HISTORY:
Homoeopathic treatment for depression __2 month’s _Not relieved.
2nd Homoeopathic treatment __2 months; not relieved.
Neurophysical treatment for stress and depression (Motival, Norgesic and Triaminic syrup)__1 month; Not relieved.
Allopathic consultation__stress diagnosed; referred to…
Neurophysical treatment for depression__2 months (Anafranil-25mg, Sedonil-3mg, Inderal-10mg); not relieved.
Neurophysical (consultation only): (Evion-200mg, Jumex-5mg, Kemadrin-5mg, Inderal 10mg)
INVESTIGATIONS:
Serum
Copper and Serum Cerulloplasmin ___
Homoeopathic treatment for cervical complaints __ 2 months; Notrelieved.
Physiotherapic consultation __ Ice-therapy __ 15 days; Aggravated cervical problem (Pain along with undue neck stiffness.)
INVESTIGATIONS:
Cervical X-Ray ___ Prevertebral muscle sprain.
Neurophysical treatment for rigidity __ 3 months (Madopar 250mg, Arthrotec 50mg, Motival); not relieved.
INVESTIGATIONS:
Urine copper and K.F. ring __NORMAL.
Neuromuscular consultation __ 2 months (PK Merz 100mg, Symmetral 100mg); not relieved__ Provisional diagnosis of Parkinson’s.
Neuromuscular consultation and treatment for Hemi-Parkinson __ 2 months (Norflex, Inderal, Baclofenac, T-zol,); not relieved.
INVESTIGATIONS:
Brain MRI__NORMAL.
Neurophysical consultation __15 days. (Evion, Loprin)
INVESTIGATIONS:
Spinal MRI___Not followed yet.
Homoeopathic treatment__2 months; not relieved.
Endocrinologist consultation;
EMG__NORMAL.
Homoeopathic treatment for neuromuscular symptoms __ 4 ½ months; not relieved.
Hakims (Ayoverdic) treatment__3months; not relieved.
Parallel homoeopathic treatment__1month; not relieved.
New homoeopathic treatment__Currently since 1 week.
FAMILY HISTORY:
Both the parents of the patient are alive. His father has a chronic history of gallstones and cataract in both eyes but is all right otherwise. His mother is a chronically hypertensive and familially diabetic Person. He has seven siblings comprising of 3 brothers and 4 sisters. All are alive and healthy. Except Diabetes, no other familial disease as Wilson’s disease, Parkinson’s or any other congenital imbalancement sorted out.
SOCIEOECONOMIC HISTORY:
Satisfactory.
SUB-VITALS:
Anemia __Not found.
Cyanosis __Not found.
Lymph nodes __Not palpable.
JVP __Not seen.
Dehydration __Not found.
Edema __Not seen.
VITALS:
B.P __
120/82 mm hg.
Resp.rate __18 breaths /min.
Pulse __ 82 beats /min.
Temperature __980F.
CNS:
Bulk, tone, power normal. Except planter reflexes all reflexes normal. No Vertigos, confusional states. Depression experienced at some times along with slight headache. Some Cogwheel rigidity on right side.
CVS:
No marks or pigmentation. Apex beat regular and easily palpable. No added sounds or murmurs audible.
RESPIRATORY SYSTEM:
Normal symmetry of the chest. Intercostals normal and no abnormal pulsations seen. Chest expands normally. No abnormal crepitations or palpitations felt. Trachea centrally placed.
GIT SYSTEM:
Abdomen normal, no abnormal marks or pigmentations seen. Umbilicus centrally placed, normal. No added sounds audible.
Abdomen is tympani tic.
REMARKS:
No abnormal findings. All systems un remarkable.
PRESENT MANAGEMENT:
In order to seek fresh
opinion, the patient met Dr, Zahir khan at the Jinnah Post Graduate Medical Centre,
No disc herniation
or any abnormal signaling was reported in the MRI. Likewise the serum cerulloplasmin and serum copper analysis showed normal
ranges.
Dr. Saleem
Ilyaas initiated drug management on 27.07.2004, with
ZnSO4, Kemadrin and Evion
capsule, which is still being followed by the patient. To this prescription,
and with a shifted prognosis towards SND__?, on 28.06.2005 .