37 year old Female suffering From low back ache
FEBRUARY 28 2022
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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
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