37 year old Female suffering From low back ache

 FEBRUARY  28 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 patients clinical problems with collective current best evidence based inputs.

        37 year 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 daily labor by occupation   has pain in the lower limbs.

She mention that she visited the  hospital in Hyderabad and there she was prescribed pain killers and she was told that if pain doesn't subside she has to under go surgery.

She has taken various pain killers for 2 years and the pain still did not subside she came to our hospital on 25th February and taking pain killers on MRI and LS spine L4 L5 paracentral disc protrusion was noticed she mentioned  that she has surgery scheduled on Monday 


PAST HISTORY

Not a k/c/o Hypertension

Not a k/c/o Diabetes mellitus


PERSONAL HISTORY

Status          : Married

Occupation : Labor

Diet         - Mixed

Appetite - Decreased

Sleep      - Decreased

Bowel movements   : Regular

Bladder movements : Regular

No issue of alcohol and Smoking intake.


GENERAL EXAMINATION

Patient is conscious , coherent, cooperative.

Patient is able to walk normally.

No clubbing of fingers or toes.

No edema of feet .

No cyanosis, pallor, icterus, lymphadenopathy, malnutrition.


VITALS

Temperature : 97.7 F

PR                 : 78

BP                 : 130/90 mm of Hg 

RR                 : 14 BPM


FINAL DIAGNOSIS

L4, L5 Paracentral disc protrusion.

L4, L5 nerve root compression.


SYSTEMIC EXAMINATION

CNS : No abnormalities detected.

CVS : S1, S2 heard, no murmurs, no thrills.

Respiratory :  No abnormalities detected.


INVESTIGATION








PLAN OF CARE

L4, L5 discectomy

TREATMENT

TAB. HIFENAC P BD
TAB. PAN 40mg OD
TAB. MUT OD



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