32 years old female with low back ache

32 YEARS OLD FEMALE WITH  LOW BACK ACHE

NOVEMBER 10 th 2022

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 available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


This Elog book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment

CHIEF COMPLAINTS 

Patient came with chief complaints of low back ache since 8 years
 
Bilateral pedal edema on and off since 1 month

Burning micturition since 7 days

Fever since 2 days

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 8 years back then she developed low back pain chronic in onset starting from buttocks and lumbar spine region and radiating up-to head,aggrevates on bending and walking and relieved on medication and lying on prone position .
No history of trauma and no history of urinary incontinence and retention. 

PAST HISTORY 

History of renal calculi 10 years back and used medication for it. 

Underwent Hysterectomy 1year back

Not a known case of HTN, DM, Epilepsy, Asthma, CAD

PERSONAL HISTORY:

Diet- Mixed
Appetite- Normal 
Sleep- Adequate 
Bowel and Bladder movements- Normal(Burning micturition is present) 

FAMILY HISTORY:
No significant family history.

GENERAL EXAMINATION:

No Pallor, Icterus, Clubbing,Cyanosis, Lymphadenopathy, Pedal Edema.


Vitals
Temperature- 97.3F
BP- 110/70mmhg
PR- 62bpm
RR- 16cpm
Spo2- 96%@room air

SYSTEMIC EXAMINATION :

CARDIOVASCULAR SYSTEM:
S1,S2 heard 
No murmurs 

RESPIRATORY SYSTEM:

BAE- present 
No wheeze
Trachea position -Central 
Breath sounds -vesicular

ABDOMINAL EXAMINATION 
 Abdomen is soft and non tender

CNS:

No focal and neurological deficits 
HMF -Normal
Pupils- Bilateral PSNL


                      Upper limb                        Lower limb

               Right             Left                   Right          Left

Tone:      Normal        Normal             Normal       Normal

Power:           5/5           5/5                    5/5              5/5

Reflexes:         Right             Left

Biceps              +                    +

Triceps            +                     +

Supinator         +                    +

Knee                +                   +

Ankle               +                    +

Plantar         Flexion        Flexion

LAB INVESTIGATIONS

HAEMOGRAM 


COMPLETE URINE EXAMINATION 


SERUM CREATININE 


BLOOD UREA


SERUM ELECTROLYTES 



 ECG


ULTRA SOUND REPORT


PROVISIONAL DIAGNOSIS 

Low back ache 

Spondyloarthritis? 

Renal tubular acidosis? 


TREATMENT 

Injection Tramadol 100 mg in 100 my NS IV stat 

Tab .ultra cut 1/2 tab

Monitoring BP, PR, RR, Temperature 6 th hourly 




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