Case history
February 26 2022
This is online E-blog, to discuss our patient de-identified health data shared after taking 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.
37 yr old female patient came with chief complaint of low back ache since 2 years associated with tingling and numbness.
HISTORY OF PRESENT ILLNESS
37 year old female who is a daily labourer by occupation has pain in the lower limbs since 2 years.
She mentioned that she visited a private hospital and there she was prescribed pain killers and she was told that if pain doesn't subside she has to undergo surgery.
She has taken various pain killers for 2 years now and the pain still did not subside.
She came to our hospital on 25th Feb and is taking pain killers.
On MRI and LS spine ,L4, L5 paracentral disc protrusion was noticed.
She mentioned that she has a surgery scheduled on 28th February.
PAST HISTORY
Not a k/c/o Hypertension
Not a k/c/o diabetesmellitus
PERSON HISTORY
Diet - mixed
Appetite - decreased
Sleep - decreased
Bowel movements : regular .
Bladder movements : regular
No history of smoking and alcohol intake.
GENERAL EXAMINATION :
patient is conscious, coherent, coperative .
Patient is able to walk normally.
No clubbing of fingers or toes.
No edema of feet.
No cyanosis,pallor,icterus,lymphadenopathy, malnutrition.
VITALS:
Temp- 97.7 F
PR- 78 BPM
BP-130/90mm of Hg
RR - 14 BPM
FINAL DIAGNOSIS:
L4, L5 paracentral disc protrusion.
L4,L5 nerve root compression.
HISTORY:
No history of trauma.
No history of any joint pains.
SYSTEMIC EXAMINATION:
CNS: no abnormalities detected
CVS: S1,S2 heard ,no murmurs,no thrills.
Respiratory: no abnormalities detected.
INVESTIGATIONS:
PLAN OF CARE:
L4, L5 disectomy
TREATMENT:
TAB. HIFENAC P BD
TAB. PAN 40mg OD
TAB. MUT OD
