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 







Comments

Post a Comment

Popular posts from this blog

Image
  43year old male came with the      chief complaints of  Fall due to loss of consciousness on 4/4/23 Hopi- Patient was apparently asymptomatic till yesterday morning then he had sudden loss of consciousness followed by fall on a cement brick and his clavicle fractured, he had similar complaint in the afternoon. No history of stiffness of both upper and lower limbs up rolling of eye balls , tounge bite . No history of fever, vomiting, neck stiffness, neck pain , and headache .  No history of visual disturbances.  No history of head trauma .  No history of sob , chest pain , palpitations, orthopnea .  Past history  K/c/o DM since 4years and was on medication  K/c/o HTN since 3 years Not a k/c/o asthma , tb , epilepsy and thyroid disorders  Personal h/o  Appetite- normal Diet - mixed Bowel and bladder - regular Any known Allergies- absent Addictions- alcohol- regular 180 ml /day , last intake yesterday morning.  Family h/o - not significant On general examination -  patient is conscious,
Read more

1801006020 - Long case

Image
24 yrs old male came to the medicine OPD with cheif complaint of unstable gait and tremors since 10 days   HISTORY OF PRESENT ILLNESSES  Patient was apparently asymptomatic 12 years ago he started drinking alcohol after  his mother passed away in a tragic accident , to alleviate that stress.  He started taking alcohol in the form of ARRACK drinking every alternative day about 1-2 glasses a day Over the next few months his consumption gradually increased to 3 glasses a  day further to 6 glasses a day.This continued upto 5 years after he started drinking .  Around 5 years later he shifted to WHISKY  due to ARRACK being banned by the government.He drink around 2 units of whisky daily before going to work and upon returning in the evening he used to feel tired thus used to drink again. In a few months time his drinking increased upto 12 units a day . patient also started chewing tobacco since the last 9 years , around 1 packet every 2-3 days He also complains of sleep disturbances,decrease
Read more

53 year old male presented to the opd with C/O swelling of back of neck 7 years and right thigh since 5 years.

Image
  This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."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 a diagnosis and treatment plan  53 year old male presented to the opd with C/O swelling of back of neck 7 years and  right thigh since 5 years. HOPI : Patient was apparently asymptomatic 7  yrs back then he developed sw
Read more