60yr old F with low back pain since 2years

 07/03/2023

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Name: K. Thanmai(intern)

Roll no: 76

Pt came to medicine OPD with complaints of

Lower back pain since 2years

Burning micturition since 3years

HOPI:

Pt was apparently asymptomatic 5years back,later developed low back pain on and off and later aggravated in past 2years,dragging type of pain,radiating from hip to mid thigh

No tingling sensation,numbness,loss of sensation

Morning stiffness present

Sacroilliac joint swelling not present

C/o burning micturition since 3years on and off

No pain during micturition,frothing during micturition,decreased urine output

Stress incontinence present(leakage during coughing)

Pedal edema present pitting type below knee

H/o fever on and off,low grade not associated with chills and rigors

H/o dry cough present aggravated during night

No h/o shortness of breath,chest pain

C/o constipation since 1year (once in every 3days)

No h/o pain abdomen,loose stools,loss of appetite,loss of weight

PAST HISTORY :

N/K/C/O HTN, DM, CVA, CAD, TB, Epilepsy

PERSONAL HISTORY :

occupation:house wife 

appetite normal 

diet non: veg 

bowels: constipation (once in 3days)

Bladder: burning micturition since 3years

Addictions:toddy drinker occasionally 

FAMILY HISTORY:

 insignificant

MENSTURAL HISTORY :

Attained menopause 5years back

GENERAL EXAMINATION :

patient is conscious cooperative coherent well oriented to time place person 

no pallor , icterus, cyanosis, clubbing , lymphadenopathy

Edema of feet present,pitting type

Vitals 

Temperature : 98.6°F

PR: 68bpm

RR:16cpm 

BP 140/90mmhg 

spo2: 96% at room air 

Systemic examination :

CVS: S1S2 heard, no cardiac murmurs heard 

RS: NVBS heard

P/A: Soft,obese abdominal wall

CNS : 

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- Both upper and lower limbs normal

                           Rt        Lt

Power-  UL:     4/5        4/5

                LL.     4/5       4/5

Reflexes          Right      Left

Biceps                 ++        ++

Triceps.              ++.        ++

Supinator           +            +

Knee.                   ++.      ++

Ankle                  ++.       ++

INVESTIGATIONS:

Hb:11.8g%

TLC:9,500cells/cumm

PLATELET COUNT:3.47 laks/cumm

PCV:36.6

CUE:

SUGARS:NIL

ALBUMIN: NIL

RBS:145mg/dl

SE.UREA:24

SE.CRETAININE:0.8

SODIUM:139

CHLORIDE:101

POTASSIUM:3.8

IONISED CALCIUM:9.4

LFT:

TB:0.60mg/dl

DB:0.20mg/dl

AKP:187IU/L

TP:6.7gm/dl

ALBUMIN:3.7gm/dl

A/G RATIO:1.24

ECG:

2D-ECHO:

EF:62%

No AR,TR,MR,

No RWMA, NO MS/AS

GOOD LV SYSTOLIC FUNCTION

No DIASTOLIC DYSFUNCTION,NO PAH/PE

USG ABDOMEN AND PELVIS:

E/O 72X48mm large exophytic cyst in lower pole of left kidney

Impression:

1)Left simple renal cortical cyst

2)Grade I fatty liver

CHEST X-RAY (LS-SPINE AP&LATERAL)

Chest X-RAY (PA VIEW)

PROVISIONAL DIAGNOSIS:

?LUMBAR RADICULOPATHY

CHRONIC UTI

TREATMENT GIVEN:

DOA:06/03/23

1)T.ULTRACET PO/QID (HALF TAB)

2)SYP.CITRALCA 15ML PO/TID

07/03/23

1)T.ULTRACET PO/QID (HALF TAB)

2)SYP.CITRALCA 15ML PO/TID

3)T.ELIWEL 10MG PO/OD(1/2 HR BEFORE FOOD)

4) PHYSIOTHERAPY (LUMBAR SPINE EXCERCISE)