75 YEAR OLD FEMALE CAME WITH THE COMPLAINTS OF LOWER BACK ACHE AND TINGLING SENSATION IN BOTH U/L AND L/L SINCE 5MONTHS

May 27, 2023

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CHEIF COMPLAINTS:

79 year old female came to the hospital with the complaints of

-lower back ache since 5 months

-With c/o burning sensation of both upper and lower limbs since 5 months

-Pain during defecation since 5 months

-fever since 10 days

HOPI:

Patient was apparently asymptomatic 5 months back. Then she complained of lower back ache which was insidious in onset,gradually progressive aggravated on bending and is relieved on medication.

She developed burning sensation of both UL and LL since 5 months which is not associated with any tingling and numbness of the limbs.

She also complaints of burning micturition since 5-6 months, nocturia present and pain during defecation which is non blood stained.

Since 10 days she complaints of low grade fever which is not associated with chills and rigor,on and off with no cough and cold.

GENERAL EXAMINATION:

Patient is conscious coherent and cooperative

No pallor ,icterus , clubbing,cyanosis,lymphadenopathy ,pedal

VITALS

BP- 130/100mmhg

PR -88bpm

RR-19cpm

Spo2 99% at room air

Temperature -98.2f

SYSTEMIC EXAMINATION:

CVS: s1,s2 heard ,no Murmurs,jvp not raised

RS: BAE,no added sounds ,NVBS,

P/A: obese,soft, non tender,bowel sounds can be heard

CNS:

Pt is conscious

Speech is normal

No meningeal signs

Normal cranial nerve examination, motor system, sensory system

GCS: E4,V5,M6

Reflexes:

R L

B ++ ++

T ++ ++

S ++ ++

K ++ ++

A ++ ++

P Flexor Flexor

CLINICAL IMAGES

INVESTIGATIONS(26/5/2023)

PROVISIONLA DIAGNOSIS

-LUMBAR SPONDYLOSIS

-PERIPHERAL NEUROPATHY

-GRADE 2-3 HAEMERROIDS

-CKD

TREATMENT

1.IV FLUIDS NS/RL @ 50ml/hr

2.INJ.LASIX 40mg IV/BD

3.INJ.HAI according to GRBS

4.TAB.NODOSIS 500mg po/bd

5.TAB.DOLO 650mg Po/SOS

6.SYP.CREMAFFIN PLUS PO/HS

SUMMARY

75 year old female came with c/o lower back ache , burning sensation in both upper limbs and lower limbs and pain during defecation since 5months