37 yr old Female With Low back ache

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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.

Name :- Kattekola Sathwik

Roll no 75

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. 

History of a first trimester spontaneous Abortion About 9 yrs ago .D and C done In Local hospital

FAMILY HISTORY:

NO SIGNIFICANT FAMILY HISTORY.

MENSTRUAL HISTORY:

LMP- 18/02/2023

Menstrual cycle- 45/5, Irregular cycles

OBS Formula- P2L2

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-

OBG referral was done on 28/2/2023 i/v/o Irregular menses and Sexual frigidity 

They advised life style modifications 

Investigations 

X ray LS AP view ON 22/02/2023

Lateral view 

Hemogram 

HB :- 12 g%

TLC :- 8600 cells/mm3

Platelet count :- 3.06 Lakhs 

Treatment given 

1. Tab.Ultracet 1/2 PO/QID X6 DAYS

2. Tab. AMYTRIPTILINE 10 mg PO H/S 

DISCHARGE SUMMARY 

Date :- 28/02/2023

Treating Faculty 

Dr.Rakesh Biswas - Professor and HOD

Dr. Nikitha- SR

Dr. Manasa - PGY3 

Dr. Keerthi - PGY2 

Dr. Vivek - PGY1 

Dr. Pranay - Intern 

Dr. Sathwik- Intern

Dr Varsha- Intern 

Dr. Sofia - Intern 

Case history and course in hospital 

The patient has Presented with the Complaints of lower back ache since 4 months..As per the patient it was non radiating , insidious in onset gradually progressive in nature. 

The patient reports that the pain aggrevated on working and standing and relieved if she sleeps or sits down. But after 5hrs of Sleep, pain gets aggrevated. Patient also reports slight difficulty  in walking up and down the stairs. 

No h/o Trauma , fever, Loss of sensation or tingling and Numbness.

The patient was then examined thoroughly For any neurological deficit and there was No neurological deficit found. An  X ray of lumbar spine - AP and PA View were taken 

The patient was taken for the Orthopedic referral in view of low back ache. They advised 

Tab. XYKAA 500 MG PO BD

Tab. PAN 40mg PO OD

Tab. SHELCAL PO OD

Tab. NEUROKIND PO HS 

The patient was then put on Tab . ULTRACET 1/2 PO QID 

The patient Also had Irregular menses with loss of sexual desire. In view of this Complaint The patient was taken for OBG Consultation..On examination, no anatomical cause of Irregular  menses was made out and patient was advised life style modifications.

The patient is hemodynamically Stable and fit for discharge 

FINAL DIAGNOSIS 

LOWER BACK ACHE DUE TO ? SECONDARY  SPONDYLOARTHROPATHY

ADVICE AT DISCHARGE 

1. LIFE STYLE MODIFICATIONS

2.Tab. XYKAA 500 MG PO BD

3.Tab. PAN 40mg PO OD

4.Tab. SHELCAL PO OD

5.Tab. NEUROKIND PO HS

6. Tab. AMYTRIPTILINE 500 MG PO HS 1 HR BEFORE DINNER