A 37year old male with lower back ache
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Case taken by P.Manogna and Shivang sharma
CASE REPORT
A 37 year old male came with the chief complaint of:
Lower back ache since 10months
HOPI:
Patient is a resident of Coochbehar of west bengal and started working as employee in private company, he uses bike to do some of the transport work.(duration- 2 to 3 hours per day)
Due to the progressive nature of pain he stopped riding bike 3months back
He was apparently asymptomatic 10months back then he developed low back ache which was insidious in onset ,gradually progressive, non radiating type ,continuous ,it aggravates on sitting for longer duration and also associated with tingling sensation so he unable to sit for longer duration, and has no relieving factors. He stopped lifting heavy weights because of back pain.
Patient had used antacids ? to relieve the pain from nearby pharmacy which was of no use , so he consulted a doctor in a local hospital in aug 2022 where he was investigated (mri and x ray was done)and was diagnosed as lumbar spondylosis and was given 6 injections Rejunuron on alt days followed by 4 injections of decadurabolin 50mg for every 3 weeks but there was no relief for the patient and was also diagnosed with hypertension and using tab .clinidipine 10mg since then .
Patient started having pain(which is non radiating,burning type of pain) and tingling sensation in left foot and upper limb-
left hand fingers since 4 months insidious in onset ,intermittent in nature so he again consulted the doctor was given medication ( tab.nervite plus for 3 weeks ) and advised for surgery if the pain has not resolved further.
PAST HISTORY:
k/c/o Hypertension since 9 months on medication (tab.clinidipine 10 mg).
k/c/o Lumbar spondylosis since 9 months.
Not a k/c/o dm,tb,epilepsy,asthma,thyroid disorders,no history of trauma.No history of surgeries.
FAMILY HISTORY:
No significant family history
PERSONAL HISTORY:
Patient completed his education until 7th standard, he got married in 2011 have two kids ,1st child is female 11 yrs old and 2nd child boy 11 months. He is an employee in private company since 2008 . He regularly starts for work at 10 am and mostly travel on bike for the work related to company until 2pm and then he takes his lunch and sits in work place from 3 pm to 10 pm . Later he goes home have dinner and sleep by 12 am.
Patient stopped working since feb 2023 because of sever backpain and also stopped riding bike
Diet: Mixed
Appetite: Normal
Sleep: adequate
Bowel and bladder movements: Regular
Addictions: Had a habit of taking alcohol occasionally since 2015 but stopped consuming completely since 1 and half year.
No allergic history.
TREATMENT HISTORY:
Tab.clinidipine 10mg daily
Inj Rejunuron forte
Inj Decadurabolin 50mg
Tab Nervite plus
GENERAL EXAMINATION
patient is coinscious coherent and co operative
Well oriented to time ,place ,person
Moderately built ,moderately nourished
Pallor -absent
Icterus- absent
Cyanosis -absent
clubbing -absent
Lymphadenopathy -absent
Pedal edema -absent
VITALS
TEMP -afebrile
PULSE RATE -86bpm
PULSE PRESSURE -120/80mmHg
RESPIRATORY RATE -16cpm
SYSTEMIC EXAMINATION
CNS EXAMINATION
HIGHER MENTAL FUNCTIONS:
Conscious, oriented to time place and person.
-Speech =Fluency,comprehension,repetition intact
-Memory =Recent,Remote,Immediate : Intact
CRANIAL NERVE EXAMINATION:
1st : Normal
2nd : visual acuity is normal
3rd,4th,6th : pupillary reflexes present.
EOM full range of motion present
5th : sensory intact
motor intact
7th : normal
8th : No abnormality noted.
9th,10th : palatal movements present and equal.
11th,12th : normal.
Motor examination :
Bulk of muscle normal on both sides on inspection
Tone
Right. Left
Upper limb. Normal. Normal
Lower limb. Normal. Normal
POWER
upper limbs +5 in all proximal and distal muscles
Lower limbs
Rt LT
Iliopsoas- +5 +5
Adductor femoris +5 +5
Gluteus medius +5 +5
Gluteus maximus. +5 +5
Hamstrings +5 +5
Quadriceps +5 +5
Tibialis anterior - +5 +5
Gastrocnemius +5 + 5
Extensor hallucis longus. +5. +5
REFLEXES
Right. Left
Biceps. ++ ++
Triceps. + + ++
Supinator. + +. ++
Knee. + +. ++
Ankle. + +. ++
Sensory examination:
1.Spinothalamic: R L
Crude touch + +
Pain + +
tingling sensation in the left foot and
Upper limb- left hand fingers
2.Posterior column:
Fine touch + +
Vibration Normal
Position sense- normal
3.Cortical
Stereognosis: + +
Graphesthesia +. +
CEREBELLUM:
Finger nose and finger finger test were normal
No dyadiadokokinesia
No pendular knee jerk
Heel knee test : normal
Spine examination:
No spine tenderness
Straight leg raising test-negative
Schober’s test-
Before-15cm
After bending-21cm
CVS:
Elliptical & bilaterally symmetrical chest
-No visible pulsations/engorged veins on the chest
-Apex beat seen in 5th intercostal space medial to mid clavicular line
-S1 S2 heard
-No murmurs
RESPIRATORY SYSTEM:
Upper respiratory tract normal
Lower respiratory tract :
-Trachea is central
-Movements are equal on both sides
-On percussion resonant on all areas
-Bilateral air entry equal
-Normal vesicular breath sounds heard
-No added sounds
-Vocal resonance equal on both sides in all areas.
PER ABDOMEN EXAMINATION
-Scaphoid
-No visible pulsations/engorged veins/sinuses
-Soft,non tender, no guarding and rigidity, no organomegaly
-Bowel sounds heard
PROVISIONAL DIAGNOSIS:
This is a case involving spine, probably due to degenerative disc pathology-lumbar spondylosis
9/05/23-Day 1
A 37 year old male with C/O lower back ache since 10months
ORTHOPAEDIC REFFERAL:
O/E
Pt is c/c/c
Temp- Afebrile
Bp-110/80mm hg
Pr- 86bpm
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact, NFND
Per abdomen : soft, non tender.
Treatment:
- TAB.CINOD 10mg/PO/OD
- PHYSIOTHERAPY
- TAB ULTRACET 1/2 TAB PO/QID
- TAB TRIGABANTIN 100mg PO/HS
10/5/23- Day 2
O/E
Pt is c/c/c
Temp- Afebrile
Bp-110/70mm hg
Pr- 73bpm
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact, NFND
Per abdomen : soft, non tender.
Treatment:
- TAB CINOD 10mg PO/OD
- TAB.HIFENAC PO/BD
- TAB. PAN 40mg PO/OD
- TAB TRIGABANTIN 100mg PO/HS
11/5/23- Day 3
O/E
Pt is c/c/c
Temp- Afebrile
Bp-130/80mm hg
Pr- 82bpm
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact, NFND
Per abdomen : soft, non tender.
Treatment:
- TAB CINOD 10mg PO/OD
- TAB.HIFENAC PO/BD
- TAB. PAN 40mg PO/OD
- TAB TRIGABANTIN 100mg PO/HS
12/5/23- Day 4
Endoscopy was done on this day
Esophagus: NORMAL
Stomach: Multiple erosions in antrum with
Small superficial ulcer
IMPRESSION:
Multiple small Antral Gastric ulcer
?NSAID induced
C/O backache
No fever spikes
Stools passed
O/E:
Pt is c/c/c
Temp- Afebrile
Bp-110/70mm hg
Pr- 62bpm
RR- 18cpm
GRBS-85mg/dl
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact, NFND
Per abdomen : soft, non tender.
Treatment:
- TAB CINOD 10mg PO/OD
- TAB.HIFENAC PO/BD
- TAB. PAN 40mg PO/OD
- TAB TRIGABANTIN 100mg PO/HS
13/5/23- Day 5
L4-L5,L5-S1 Lumbar spondylosis
Gastric ulcer ?NSAID induced
C/O low backache
Tingling sensation in the back
No fever spikes
Stools passed
O/E:
Pt is c/c/c
Temp- Afebrile
Bp-120/80mm hg
Pr- 76bpm
RR- 18cpm
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact, NFND
Per abdomen : soft, non tender.
Treatment:
- TAB CINOD 10mg PO/OD
- TAB.HIFENAC PO/BD
- TAB. PAN 40mg PO/OD
- TAB TRIGABANTIN 100mg PO/HS
- TAB AMITRYPTALLINE 10mg/PO/HS
14/5/23- Day 6
L4-L5,L5-S1 Lumbar spondylosis
Gastric ulcer ?NSAID induced
O/E:
Pt is c/c/c
Temp- Afebrile
Bp-120/80mm hg
Pr- 76bpm
RR- 18cpm
GRBS-123mg/dl
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact, NFND
Per abdomen : soft, non tender.
Treatment:
- TAB CINOD 10mg PO/OD
- TAB.HIFENAC PO/BD
- TAB. RAZO-D 40mg PO/OD 7AM
- TAB TRIGABANTIN 100mg PO/HS-9PM
- TAB AMITRYPTALLINE 10mg/PO/HS
15/5/23- Day 7
O/E:
Pt is c/c/c
Temp- Afebrile
Bp-110/80mm hg
Pr- 80bpm
RR- 16cpm
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact, NFND
Per abdomen : soft, non tender.
Treatment:
- TAB CINOD 10mg PO/OD
- TAB.HIFENAC PO/BD
- TAB. RAZO-D 40mg PO/OD 7AM
- TAB TRIGABANTIN 100mg PO/HS-9PM
- TAB AMITRYPTALLINE 10mg/PO/HS
16/5/23- Day 8
O/E:
Pt is c/c/c
Temp- Afebrile
Bp-120/80mm hg
Pr- 75bpm
RR- 18cpm
Spo2: 98% on RA
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact, NFND
Per abdomen : soft, non tender.
Treatment:
- TAB CINOD 10mg PO/OD
- TAB.HIFENAC PO/BD
- TAB. RAZO-D 40mg PO/OD 7AM
- TAB TRIGABANTIN 100mg PO/HS-9PM
- TAB AMITRYPTALLINE 10mg/PO/HS
FINAL DIAGNOSIS:
1. L4- L5, L5-S1 LUMBAR SPONDYLOSIS WITH ACID PEPTIC DISEASE
2. (GASTRIC ULCERS ?NSAID INDUCED)
3. WITH K/C/O HTN SINCE 10 MONTHS
Treatment Given
1.TAB CINOD 10MG PO/OD @8AM
2.TAB HIFENAC-P PO/OD
@8AM AND 8PM
3.TAB RAZO-D 40MG PO/OD @7AM for 5days
HALF AN HOUR BEFORE BREAKFAST
4.TAB TRIGABANTIN 160MG PO/HS @9PM
5.TAB AMITRIPTYLINE 10MG PO/HS @9PM
COURSE IN HOSPITAL
Patient was referred to orthopaedic and endoscopy was done and found out to have Multiple small antral gastric ulcers
And was treated with TAB RAZO-D 40MG PO/OD @7AM for 5days if symptoms are present
Advice At Discharge
1.TAB CINOD 10MG PO/OD 8AM
2.TAB TRIGABANTIN 160MG PO/HS 9PM
3.TAB AMITRIPTYLINE 10MG PO/HS 9PM
4.TAB.RAZO-D 40MG PO OD 7AM BEFORE BREAKFAST(SOS)(If symptoms present)
5.TAB.ULTRACET 1/2TAB QID (SOS)
6.PHYSIOTHERAPY
7.AVOID SPICY FOOD INTAKE
8.WELL BALANCED DIET (with salt restriction) and REGULAR PHYSICAL ACTIVITY
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