37 YEAR OLD FEMALE

 Name: KP PRANAY 

Roll no. 81

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.

Following is the view of my case:

CHIEF COMPLAINTS:

Patient came with the chief complaints of low back ache since 4 months.

HOPI:

Patient was apparently asymptomatic 4 months back, then she developed pain which was insidious in onset and gradually progressive

Pain aggravated on bending forward and walking fast.

Relieved on lying down, but again aggravated after 5 hours of sleeping.

No H/O tingling sensations/ numbness

H/O slight difficulty in walking up and down the stairs.

Patient C/O low back pain more in winters

Patients routine-

Patient was housewife by occupation.

She has 2 kids who are studying in school.

She used to stay at home, have food and watches television.

6am- wakes up, and do some household works like sweeping, cooking, laundry

9am- eats breakfast (tea and biscuits), and cooks food

11am- eats lunch (rice with fish/dhal etc)

3pm- eats same dishes again, and sleeps for 2 hours, watches television

5pm- drinks tea, makes her kids study

10pm- eats dinner (rice with curries)

11pm- Sleeps and wakes up in the middle of the night after 5 hours of sleeping due to low back pain.

PAST HISTORY:

Not a known case of DM, Hypertension, Epilepsy, Asthma, Thyroid disorders, CVA, CAD.

PERSONAL HISTORY: 

The patient is housewife by occupation.

Diet - mixed

Appetite- Normal

Bowel and bladder movements -regular

Sleep- Adequate

Addictions - no addictions

SURGICAL HISTORY: 

2 previous LSCS in 2009 and 2015.

The 2nd LSCS is followed by HYSTERECTOMY in 2015. 

FAMILY HISTORY:

NO SIGNIFICANT FAMILY HISTORY.

MENSTRUAL HISTORY:

LMP- 18/02/2023

Menstrual cycle- 45/5, Irregular cycles

OBS Formula- G2P2

GENERAL EXAMINATION: 

Patient is C/C/C

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.

Vitals: 

BP- 130/70mmhg

Temp- Afebrile

PR- 78bpm

RR- 16cpm 

SpO2 - 99% @ Room air 

SYSTEMIC EXAMINATION: 

CVS: S1,S2 heard ,no murmurs 

RS: BAE +, no crepts

P/A: soft, non tender, 

        Bowel sound heard

O/E:

Spinal tenderness @ L4 and L5

SLRT- (-ve)

Schobers test- (-ve)

CNS- NFDF

Reflexes-  B.    T.     S.     A.    K.    

Right-       2+    2+   1+    2+    2+     

Left-.        2+    2+    1+    2+    2+  

Orthopedic referral done on 23/02/23-

INVESTIGATIONS:

On 22/02/23-

X-Ray LS Spine-

                                                  AP View

                                     Lateral view             

DIAGNOSIS:

LOW BACK ACHE---? RADICULOPATHY

                                 ?SACROILITIS

                                 ?ENTHESITIS

TREATMENT:

On 23/02/23-

Tab. Ultracet (1/2 tab)PO/ QID