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Hyndavi Konakanchi, Intern
23/12/22
A CASE DISCUSSION 38/F WITH LOWER BACK PAIN AND LIMB WEAKNESS
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 :
Pt came with the cheif complaints of left lower back pain since 3 yrs
Pt was apparently asymptomatic till 10 yrs ago ; then she had headache radiating to neck accompanied by nausea and vomiting , she visited ophthalmologist for the same and prescribed spectacle & medications ( unknown) she continued medications for 1 yr and changed spectacles once a year for 6 yrs and stopped using them. Headache resolved
Three years ago , while she is working in the field she had inscidious onset of burning micturition ; for which she drank lot of water thinking it as sun stroke - later in the night she had urinary incontinence. Next morning she went to RMP and got an IV inj. ( not resolved ) , so went to private hospital in Hyderabad and was said she had renal cysts ( reports not available) , was prescribed medications for same ehich she used for 6 months , during the course she had intermittent back pain; often usef zandu balm topically to releive pain
Since 5 months she feels itching in the ear followed by dragging type of headache on left temporal region accompanied by neck pain ; strained eyes , blurring of vision and loss of sense in taste. Releives on medicines
Back pain is inscidious in onset and non progressive , localised to lt lumbar region ; pain is dragging type and non radiating type of pain
H/o giddiness + , giddiness +
No H/o burning micturition, nausea, vomiting, fever, chestpain , SOB, loss of appetite, weight loss, insomnia
SURGICAL HISTORY:
H/o tubectomy 19 yrs ago
H/o hysterectomy 14 yrs ago
BLOOD TRANSFUSION:
H/o 1 unit blood transfusion 14 yrs ago
MEDICAL HISTORY:
Not a K/C/O HTN/ DM/ asthma / Ischemic heart disease / epilepsy / TB
FAMILY HISTORY
No significant family history
PERSONAL HISTORY
OCCUPATION : Farmer
DIET : Vegetarian
APPETITE : Normal
SLEEP : Normal
BOWEL AND BLADDER HABITS : Normal
ADDICTIONS: No
GENERAL EXAMINATION
* Patient is concious coherent and coperative, well oriented to time palce and person
* Built - moderately built , moderately nourished
VITALS
Blood pressure : 130/90 mm hg
Pulse Rate : 100 bpm
Temperature : 98.6 degrees F
SPO2 : 98 @ RA
GRBS : 120 mg/dl
PALLOR : PRESENT
* NO ICTERUS , CYANOSIS, CLUBBING , LYMPHADENOPATHY
SYSTEMIC EXAMINATION:
CVS - S1,S2 heard , no added sounds
RS - BAE + , NVBS
PA - soft , NT , BS +
GCS - E 4 V 5 M 6
CNS -
Power - UL : rt - 5/5 , lt - 5/5
LL : rt - 5/5 , lt - 5/5
Tone - UL : rt - N , lt - N
LL : rt - N , lt - N
Reflexes - B T S K A plantar
Rt : + + + + + flexion
Lt : ++ ++ ++ ++ ++ extension
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS:
Left lower back pain under evaluation
Headache under evaluation
TREATMENT:
Tab. Ultracet PO / QID
Monitor vitals
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