42 year old man reported with dull aching pain in the right side of the abdomen. He has suffered with this pain for the past 6 months. This pain used to radiate to his chest as well as the back.

This is a case of Mr. N. M. (Patient identification number: L-8748), a 42 year old male who reported to the clinic with dull aching pain in the right side of the abdomen. He has suffered with this pain for the past 6 months. He registered for the treatment on August 5, 2006 . This pain used to radiate to his chest as well as the back.

He had this pain almost daily. This was associated with heaviness in the abdominal region. There was always a feeling of tightness in his abdomen. On further interrogation, he revealed that he has some non specific and very mild pain all over the abdomen for the past 6 years or so. He also experienced nausea on many occasions.

The nausea was worse in the mornings and when he was too anxious about any issue. He used to pass sticky stools and his bowels were always unsatisfactory. He however has semisolid stools and there was no history of associated bleeding or mucus passed with the stools. He had bowel movements twice in a day. He also had burning sensation in the chest which was extending to his throat. This sensation was worse with the slightest intake of spicy food.

Past treatment: He had been receiving antacids namely T. Esamoprazole 40 mg, 1 tablet a day since the past 1 year. He was on similar group of drugs on and off since the past 3 years.

Associated complaints: He also complained of pain in his left shoulder since the past 1 year. There was no history of any restricted movements. This pain would last only for a minute or so. The pain was worse when getting up in the morning or by any form of sudden movements.

There was no history of any associated tingling numbness in the hand. He had been treated with steroid injection for this pain in November 2005, where in his orthopedic doctor had diagnosed his problem as Left shoulder bursitis.

Personal history: His diet was mixed. His appetite was diminished. He had some crazing for sweets. He was markedly sensitive to cold environment. He sleep used to be disturbed most of the times. He therefore had to take T. Alprazolam (which is known to induce sleep). He used to take it at least twice to thrice in a month.

Constitution: He was a man with an average built and dark complexion.

Family set up: His family comprised of his wife (who was a homemaker). He had 2 sons (15 and 4 years). He was a computer consultant and working with a renowned computer company.

Emotional sphere: He was a very emotional person and used to get hurt easily. He thinks a lot about very trivial issues and then he slowly cools down. He was always very stressed about his various health issues. This anxiety about health was also pertaining to his children. He was also cheerful by nature. He has marked anxiety which was expressed at various fronts. He used to be very anxious when he wanted to go out somewhere, for e.g. for a meeting; he would be anxious whether or not he is thoroughly prepared, whether he would perform well or not. While in office also he would be very worried as to someone will dash his case which he has parked downstairs. He used to suppress his anger because he did not want to hurt anyone.

Past history: He used to have recurrent ear infections especially in the left ear. He was however asymptomatic currently.

Family history: His father had an episode of acute myocardial infarct, and was a known hypertensive. His mother was also a known case of hypertension and had suffered with brain tumor as well. His elder sister was also a known case of hypertension.

Follow up details:

5.08.06:
Based on his case details, he was prescribed Thuja in the 200th potency two doses. With this he was also prescribed Nux Vomica in the 200th potency 4 pills to be taken thrice in a day for 3 weeks.

23.08.06:
He reported that his symptoms were around 90% better. There was however a recurrence of complaints since the past 4 days due to the consumption of spicy food. During this period he had also skipped antacids and hence he faced a lot of problem all of a sudden. He however resumed to his T. Esamaprazole 20 mg daily dose. His treatment was continued on similar lines and this time the medicines were given for a period of 8 weeks.

7.10.06:
He reported to have 90% improvement in his symptoms. He had these complaints once a week and it lasted for only 15 minutes or so. He however gets frequent bouts of abdominal pain which are always mild in severity. His anxiety and depression though continue to be the same. In the meanwhile he also seems to have consulted a psychiatrist just a month back who has prescribed T. Mirtaz 30 mg daily dose and T. Zapic 0.5 mg daily dose.
His left shoulder pain is also now much better. He does not have any other major complaints as well
Considering that he has responded very well to the current line of treatment, we did not make any changes in his protocol and was given the same batch of medication for another 4 weeks.

1.11.06:
He reported that his complaints were almost 95% better now. The anxiety has reduced to some extent. The pain in his left shoulder had almost disappeared and would come only when he had some kind of sudden movement.
At this visit he complained about having burning sensation with itching while passing stools. This was a recent complaint and he had it only for the past 4 days. There was no history of bleeding per rectum.
In his course of treatment medication had been administered for this complaint as well, in association with his regular medication for GERD.
He is advised to continue treatment and report to us after 6 weeks.

Remarks:
With continuous treatment, I strongly believe that the patient would be much better and we shall keep you all readers updated about the same.