56 yr female with lower back ache

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."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.


Complaints: 


C/o lower backache since 6 months 

C/o tingling sensation of whole body since 6 months


HOPI:


Pt was apparently asymptomatic 6 months ago then developed c/o lower backache not a/w stiffness or tenderness.

C/o tingling sensation of whole body not a/w paraesthesia or numbness.

H/o ? Monoparesis rt UL 6 months ago which improved after 2-3 days and residual weakness of grip strength present.


Past illness:


Not a k/c/o HTN, DM, thyroid disorders,epilepsy, CVA, CAD, asthma.


Personal history:


APPETITE decreased since 6 months 

DIET MIXED

BOWEL- constipation -once in 5 days

BLADDER REGULAR

SLEEP ADEQUATE

NO KNOWN ALLERGIES 


NO SIGNIFICANT FAMILY HISTORY


General examination-


Patient is C/C/C

BP-130/80mmhg

PR- 86 bpm

RR- 18cpm

Temp- afebrile


SYSTEMIC EXAMINATION 


CVS- S1S2+,NO MURMURS

RS- BAE+,NVBS HEARD

P/A- SOFT,NON TENDER,BOWEL SOUNDS+

CNS- ORIENTED TO TIME,PLACE AND PERSON


Clinical images and investigations:























Diagnosis : Lower back ache under evaluation

H/o monoparesis of rt UL 6 months ago.


Treatment


  1. T. Ultracet PO/BD
  2. T. Pregaba 75mg PO/HS


Summary


Diagnosis : Lower back ache under evaluation

H/o monoparesis of rt UL 6 months ago.


Complaints: 


C/o lower backache since 6 months 

C/o tingling sensation of whole body since 6 months


HOPI:


Pt was apparently asymptomatic 6 months ago then developed c/o lower backache not a/w stiffness or tenderness.

C/o tingling sensation of whole body not a/w paraesthesia or numbness.

H/o ? Monoparesis rt UL 6 months ago which improved after 2-3 days and residual weakness of grip strength present.


Past illness:


Not a k/c/o HTN, DM, thyroid disorders,epilepsy, CVA, CAD, asthma.


Personal history:


APPETITE decreased since 6 months 

DIET MIXED

BOWEL- constipation -once in 5 days

BLADDER REGULAR

SLEEP ADEQUATE

NO KNOWN ALLERGIES 


NO SIGNIFICANT FAMILY HISTORY


General examination-


Patient is C/C/C

BP-130/80mmhg

PR- 86 bpm

RR- 18cpm

Temp- afebrile


SYSTEMIC EXAMINATION 


CVS- S1S2+,NO MURMURS

RS- BAE+,NVBS HEARD

P/A- SOFT,NON TENDER,BOWEL SOUNDS+

CNS- ORIENTED TO TIME,PLACE AND PERSON


Treatment


  1. T. Ultracet PO/BD
  2. T. Pregaba 75mg PO/HS

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