Case of 45 year old lady with lower back pain

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Neha Tipparaju 

Roll no. 100 


Case of 45 year old lady with lower back pain 

My case is of a 45 year old lady, agricultural worker by occupation and resident of Nalgonda, who came with the complaints of: 

           Lower back pain since 1 year. 

           Weakness of right lower limb since 2 days

History of presenting illness: 

Patient was apparently assymptomatic 1 year back when she developed a lower back ache. This pain was incidious in onset gradually progressive for a duration of 1 year.

The pain is a dragging type, which  radiates along the right limb and is aggrevated on continuous standing or walking and relieved on rest and medication of NSAIDs, which she has been taking for 6 months, on the advice of an orthopaedician.  He directed her to get a Lumbar MRI and advised her for surgery, which she did not follow through due to personal issues in the family. 

No history of any fall or trauma

Patient had difficulty in passing stools (constipation) since 1 month for which the patient went to the nearby doctor 2 days back. She was put on Syp. Lactulose and after 1 day, the patient had 5 episodes of watery stools for 1 day, 2 episodes of vomitings for 1 day which subsided now. 

The patient is also complaining of generalized weakness since 2 days

Presently the patient is not complaining of any fever, cough, headache, diarrhoea, vomitings, burning micturition or suprapubic pain. 



Past history:

No similar complaints in the past 
 
Not known to be having Diabetes mellitus, hypertension, tuberculosis, asthma, epilepsy, coronary artery disease or cerebro vascular accidents. 

Previous surgeries/ interventions: Hysterectomy 10 yrs back
                                                               ECSL for Right Renal stones  6 years back, 
                                                               Left Cataract Surgery 6 yrs back.

Using NDAIDs for the last 6 months for back pain. 


Personal history:
P3L3 

Diet- mixed

Appetite- Reduced due to pain

Sleep- Adequate

Bowel and bladder movements- Regular

No known allergies

No addictions 

Family history:  Not significant 

General Examination: 

Patient is examined in a well lit room after obtaining informed consent. She is conscious, coherent and cooperative, well oriented to time, place and personn, moderately built and nourished. 

On examination: 

Pallor: Mild

Icterus, cyanosis, clubbing, koilonychia, generalized lymphadenopathy or edema are not observed. 

Vitals:
Temp.- Afebrile

BP- 110/70 mmHg

PR- 100 bpm

RR- 12 cpm

SpO2- 98%

GRBS- 138 mg/dL 






Systemic Examination 

CNS: 

Higher mental functions:

Oriented to time,place,person

Memory : recent, remote intact

Speech: normal, understandable

No delusions or hallucinations



Cranial nerves: 

1- not tested

2- binocular vision: normal

colour vision:normal

3,4,6- No restriction of movement of eye

5-normal( muscles of mastication+sensations of face) No jaw jerk

7-Normal, wrinking of forehead seen, able to blow up cheeks

8- Normal hearing

9,10,11,12-normal. Gag reflex is normal.



Motor examination:

Tone -normal

Power 

-4/5 in right lower limbs 

5/5 in  left lower limb and upper limbs



Reflexes :

Biceps:b/l:2+

Triceps:2+

Supinator 2+

Knee: Right:  1+
           Left: 3+ 

Ankle: Right: 1+ 
             Left: 2+ 

Plantars: Decreased response on right side





Sensory examination:

Crude touch, pain ,temp, fine touch, joint position, proprioception are normal in all dermatomes in upper limbs.

Crude touch and pain are decreased on all dermatomes of right lower limb.


Cerebellum examination:

Able to do finger nose test.

No dysdiadokinesia 

No rebound tenderness 



Autonomic Nervous System:

No postural hypotension 

No bladder and bowel incontinence 

No sweating abnormalities



Meningeal signs:

No meningal signs like Brudzinski or Kernig sign were positive 



Gait: did not walk due to pain



CVS: S1 S2+ no murmurs heard.

Respiratory system- Bilateral air entry+ ,normal vesicular breath sounds-heard. 

Abdominal: Soft, non tender, no distension, umbilicus is central and inverted,no scars, no sinuses, hernial orifices free. 


Investigations: 


Renal function tests:



Significant findings: Microcytic hypochromic anemia, Low platelets, elevated creatinine and urea 

Ultrasonography: 



X ray: 





MRI :
(On orthopaedic advice) 






PROVISIONAL DIAGNOSIS:
AKI secondary to ?analgesic neuropathy 


TREATMENT GIVEN:
1. IV Fluids NS and RL @ UO+50 ml/h
2. Inj. Optineuron 1 amp in 100 ml NS
3. Inj. PANTOP 40 mg IV OD
4. Inj. Lasix 20 mg IV BD (if sBP>110 mmHg)
5. Inj. Neomol 100 ml IV SOS (if temp>101 F)
6. Tab. PCM 500 mg PO SOS
7. GRBS - 6th hrly
8. I/O Charting
9. Monitor vitals 4th hrly

Orthopaedic referral:



Nephrology referral: 

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