50 F presented with low back pain

 

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I have 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 diagnosis and treatment plan.This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

50/F resident of Nidamanuru presented with 

complaints of  

    low back pain since 1 year

   Pain abdomen since 1 year 

   Burning micturition since 1 year

Hopi 

Patient was apparently asymptomatic 1 year back,then developed low back pain ,insidious in onset ,gradually progressive,radiating down along both thighs,associated with tingling sensations of both feet,releived on taking medication and rest.

H/o pain abdomen ,in the epigastric region,burning type,insidious in onset,non radiating,releived on taking medication and aggravated on taking spicy foods,associated with bloating and belching

No H/o regurgitation of food,nausea,vomiting

H/o burning micturition on and off from the past 1 year ,consulted at a pvt hospital where pt

Is treated symptomatically and got releived ,again from the past 6 mon pt is having burning micturition

H/o pain in both knees since 1 year

H/o pedal edema (on and off) from the past 1 year, releived on rest

H/o Constipation+

No H/o fever

No H/o chest pain,SOB,Palpitations

No H/o frothing of urine

No H/o renal calculi

No H/o analgesic abuse

H/o hysterectomy 13 years back(i/v/o ?Fibroid)

K/c/o T2 DM Since 3 months(on Tab Metformin 500mg once daily)

Not a k/c/o HTN,asthma,Thyroid disorder ,epilepsy,TB

Personal h/o 

Appetite- normal

Diet - mixed

Bowel and bladder - regular

Any known Allergies- absent

Addictions - no 

Family h/o - not significant 

On general examination -

patient is conscious,coherent and cooperative 

Well oriented to time , place and person. 

There is no pallor, icterus, cyanosis, clubbing, lymphadenopathy and 

bilateral pedal edema - present, pitting type Extending above ankle till knee 

Afebrile on touch

PR-92bpm

Bp-130/80mm hg

RR-16cpm

Grbs-151mg/dl

Cvs-s1,s2+

        Jvp- not raised

Rs-BAE+

CNS- Nfnd

P/A -soft,nontender  

Provisional diagnosis -

Pedal Edema under evaluation 

K/c/o DM t2 Since 3 yrs with lumbar spondylosis L5-S1 

Investigations  

USG 

Grade 1 fatty liver 

2D echo 

Tribal AR+ , no MR/TR 

No Rwma , no AS/MS 

ECG

Treatment 

1. Tab METFORMIN 500 mg pO, OD

2. Syp LACTULOSE 15mI pO /HS 

3. T. Ultracet 1/2 tablet po Qid 

4. Tab pan 40 mg  po / od BBF 

5. T. Shelcal po/od 

6. Cap. VIT D3 60k U once a week 

7. LS belt 

8. Avoid heavy weight lifting