A 43 YR OLD FEMALE WITH LOWER BACK PAIN
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
A 43 year old female Complaints of lower back pain since 6 years
HOPI : she was apparently asymptomatic 6 yrs ago, then she developed lower back pain ,Which was radiating to lower limbs
Then she went to a local hospital ,there she was diagnosed as to have spinal canal stenosis . She complains of tingling sensation , numbness & tenderness over L4-L5/ L5-S1
MRI report shows(21/11/14)
Past history
Not a k/c/o DM HTN,TB Epilepsy,cad ,asthma
Personal history
Takes mixed diet
Appetite -normal
Sleep- adequate
Bowel and bladder - regular
Addictions- no known addictions
General physical examination
Pt is C/c/c
Moderately built and nourished
No pallor ,icterus , clubbing , cyanosis, lymphadenopathy,odema of feet
Vitals-
Temp- afebrile
bp-130/80 mmHg
Pr-89bpm
Rr-15 CPM
Systemic examination-
Cvs- S1S2 +
Rs- BAE+
P/a - soft ,non tender,bowel sounds+
Cns- NFAD
ORTHO REFERRAL DONE ON 5/11/21
MRI
X ray L-S spine on flexion and extension
Dvl referral
Provisional diagnosis
Lumbar canal stenosis
Xanthelasma palpebrarum
?onychomycosis
Treatment
Tab.pan 40 mg po od
Tab.gabapentin 100 mg PO OD X 1 month
Tab.neurokind lc po od X 1 month
Tab.hifenac X 5 days
Core strengthening exercises
Loceryl nail lacquer L/A bd X 2 weeks
Tab.follihair od 2 weeks
Tab.mvt po OD
DISCHARGE SUMMARY :
A 43 yr old female complaints of lower back pain since 6 yrs
HOPI : she was apparently asymptomatic 6 yrs ago, then she developed lower back pain ,Which was radiating to lower limbs
Then she went to a local hospital ,there she was diagnosed as to have spinal canal stenosis . She complains of tingling sensation , numbness & tenderness over L4-L5/ L5-S1
Past history
Not a k/c/o DM HTN,TB Epilepsy,cad ,asthma
Personal history
Takes mixed diet
Appetite -normal
Sleep- adequate
Bowel and bladder - regular
Addictions- no known addictions
General physical examination
Pt is C/c/c
Moderately built and nourished
No pallor ,icterus , clubbing , cyanosis, lymphadenopathy,odema of feet
Vitals-
Temp- afebrile
bp-130/80 mmHg
Pr-89bpm
Rr-15 CPM
Systemic examination-
Cvs- S1S2 +
Rs- BAE+
P/a - soft ,non tender,bowel sounds+
Cns- NFAD
MRI L-S SPINE IMPRESSION
-L4-L5 posterior annular fissure with central disc protruding and bilateral facet hypertrophy causing moderate to severe central canal stenosis
-L5-S1 diffuse disc bulge causing canal stenosis
-26x20 mm anterior intramural fibroid in uterus
DIAGNOSIS
Lumbar canal stenosis
Xanthelasma palpebrarum
?onychomycosis
PLAN OF TREATMENT
Tab.pan 40 mg po od
Tab.gabapentin 100 mg PO OD X 1 month
Tab.neurokind lc po od X 1 month
Tab.hifenac X 5 days
Core strengthening exercises
Loceryl nail lacquer L/A bd X 2 weeks
Tab.follihair od 2 weeks
Tab.mvt po OD
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