50 F presented with low back pain


50/F resident of Nidamanuru presented with 


complaints of  

     low back pain since 1 year

   Pain abdomen since 1 year 

   Burning micturition since 1 year

Hopi 

Patient was apparently asymptomatic 1 year back,then developed low back pain ,insidious in onset ,gradually progressive,radiating down along both thighs,associated with tingling sensations of both feet,releived on taking medication and rest.

H/o pain abdomen ,in the epigastric region,burning type,insidious in onset,non radiating,releived on taking medication and aggravated on taking spicy foods,associated with bloating and belching

No H/o regurgitation of food,nausea,vomiting

H/o burning micturition on and off from the past 1 year ,consulted at a pvt hospital where pt

Is treated symptomatically and got releived ,again from the past 6 mon pt is having burning micturition

H/o pain in both knees since 1 year

H/o pedal edema (on and off) from the past 1 year, releived on rest

H/o Constipation+

No H/o fever

No H/o chest pain,SOB,Palpitations

No H/o frothing of urine

No H/o renal calculi

No H/o analgesic abuse

H/o hysterectomy 13 years back(i/v/o ?Fibroid)

K/c/o T2 DM Since 3 months(on Tab Metformin 500mg once daily)

Not a k/c/o HTN,asthma,Thyroid disorder ,epilepsy,TB


Personal h/o 

Appetite- normal

Diet - mixed

Bowel and bladder - regular

Any known Allergies- absent

Addictions - no 


Family h/o - not significant 


On general examination -

patient is conscious,coherent and cooperative 

Well oriented to time , place and person. 

There is no pallor, icterus, cyanosis, clubbing, lymphadenopathy and 

bilateral pedal edema  - present, pitting type Extending above ankle till knee 




Afebrile on touch

PR-92bpm

Bp-130/80mm hg

RR-16cpm

Grbs-151mg/dl

            


Cvs-s1,s2+

        Jvp- not raised

Rs-BAE+

CNS- Nfnd

P/A -soft,nontender  



Provisional diagnosis -

Pedal Edema under evaluation 

K/c/o DM t2 Since 3 yrs with lumbar spondylosis L5-S1 

Investigations  

USG 

Grade 1 fatty liver 

2D echo 

Tribal AR+ , no MR/TR 

No Rwma , no AS/MS 

 












ECG 


Treatment 


1. Tab METFORMIN 500 mg pO, OD


2. Syp LACTULOSE 15mI pO /HS 



3. T. Ultracet 1/2 tablet po Qid 


4. Tab pan 40 mg  po / od BBF 


5. T. Shelcal po/od 


6. Cap. VIT D3 60k U once a week 


7. LS belt 


8. Avoid heavy weight lifting 







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