45 YEAR OLD WITH COMPLAINTS OF BACK PAIN SINCE 8 MONTHS

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Name : Ankitha

Roll no : 78

 

I’ve 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 

A 45 year old male from Bengal businessman by occupation came with chief complaints of Back pain since 8 months.

HOPI:

Patient was apparently normal 10 years back. He then was operated for acute appendicitis under spinal anaesthesia. 

Since then patient was experiencing back pain which was insidious in onset and gradual in progression 

Back pain increased since the last 8 months  and progressed to present stage.

Pain is aggravated on standing for more than 15-20 minutes, sitting for long time, bending forward or when lifting weights and is only relieved on completely lying on the bed. 

Pain is non radiating without any tingling sensation or numbness.

Patient also complaints of neck pain since one month, non radiating , no tingling sensation and no headache or nausea or vomitings or giddiness.

Patient also complaints of cold and cough with sputum since two days along with throat irritation.

No history of fever, trauma, chest pain, pain abdomen, SOB

PAST HISTORY:

Patient is a known case of Type II Diabetes Mellitus on medication since 4 years 

Presently using -

Tab Glimeperide 1mg+ Pioglitazone 15mg+ Metformin 1000mg in the morning

Tab Glimeperide 2mg + Metformin 500mg in the night Tab Tenegliptin 20mg at night.

Also a known case of Hypertension since 5 years presently using Tab Olmesartan 20mg+ Amplodipine 5mg+ Hydrochlorothiazide 12.5mg at night.

H/o fracture right clavicle 5years back in a RTA

Not a known case of CVA, CAD, Asthma, TB, Thyroid disorders, Epilepsy 

Surgical History-

Operated for Acute Appendicitis 10years back.

PERSONAL HISTORY:

Diet : mixed

Appetite : normal

Sleep : normal

Bowel and Bladder : Regular

No Allergies

Occasional alcoholic since 25 years.

Smoker since 25 years , he smokes occasionally.

FAMILY HISTORY:

Mother is Diabetic and Hypertensive 

Father is Hypertensive.

ON EXAMINATION:

Patient is conscious, coherent, cooperative

Afebrile on touch

PR -78bpm

BP - 130/90 mm hg

RR -18cpm

RS - BAE present, NVBS, no added sounds

CVS - S1 S2 heard, no murmurs

P/A - soft, no tenderness

CNS:

HIGHER MENTAL FUNCTIONS- INTACT

MEMORY- ABLE TO RECOGNISE HIS FAMILY MEMBERS AND RECALL RECENT EVENTS SPEECH: NORMAL

CRANIAL NERVE EXAMINATION- NORMAL REFLEXES-

                      RIGHT          LEFT

BICEPS            2+                 2+

TRICEPS          2+                 2+

SUPINATOR     1+                1+ 

KNEE                2+                2+

ANKLE.            2+                 2+

SUPERFICIAL AND DEEP REFLEXES ARE PRESENT AND NORMAL

MUSCLE POWER- 

                                    RIGHT           LEFT 

UPPER LIMB  

ELBOW                         5/5                  5/5 

WRIST                           5/5                  5/5 

HAND GRIP                  5/5                  5/5

LOWER LIMB 

HIP                                   5/5                 5/5 

KNEE.                              5/5                 5/5 

ANKLE                            5/5                 5/5

TONE- NORMAL IN UPPER AND LOWER LIMBS

NO INVOLUNTARY MOVEMENTS

SENSORY SYSTEM- ALL SENSATIONS ARE NORMAL.

SLRT-at 75degree C/O pain on both sides

Schober’s test- negative 

Course in hospital :

Orthopaedics referral done 

L5 S1 space decreased

Advice :

Tab . Hifenac P Po/OD

Tab. PANTOP Po/OD BBF

Physiotherapy

INVESTIGATIONS:

Radiographs :

FBS-135

PLBS-197

PROVISIONAL DIAGNOSIS :

BACK PAIN UNDER EVALUATION

? LUMBAR SPONDYLOSIS.

TREATMENT :

Tab ULTRACET 1/2 tab PO/QID

Advice at discharge :

Tab ULTRACET 1/2 tab PO/QID x 3 days 

Physiotherapy

Follow up : 

Review Sos to General medicine opd