40 YR FEMALE CAME WITH C/O UPPER AND LOWER BACKACHE SINCE 2 YEARS

 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.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


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


The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 


A  40 YEAR OLD FEMALE WHO IS RESIDENT OF WEST BENGAL CAME  WITH 

CHIEF COMPLAINTS  OF:

Pain in upper and lower back since 2 years.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently alright 2 years ago then she had pain in upper and lower back which is insidious in onset and gradually progressive to current condition, pain was radiating to the sides and the neck, relieving on taking medication and physiotherapy.

Pt had history of travelling on bike upto approx 48kms for 10 yr  and she is working as a teacher,

Since 2 yrs she had increased pain in the back and  now she is going to school by car. Past 1 yr there is severe pain in back even after doing physiotherapy  and her husband also noticed some abnormality in shoulder position (unequal shoulder position)and back(structural) and went to local hospital and they advised x -ray whole spine  in which they diagnosed scoliosis and  they said it may require surgical correction . After that now they approached our hospital.

 she also complains  of pain in the right shoulder while writing with chalk on board and stops writing and continues in a while. Patient also gives h/o pain during work on bending forward and relieving on standing straight or lying on flat surface. Patient is unable to sit straight for a long time and leans back for support.

Patient is unable to sleep in supine position  and preferred to sleep on one side.

No h/o tingling or numbness in the back and lower limbs.

Pt also c/o easy fatiguability and shortness of breath (grade II) since 10 yrs.

No h/o fever, cold , cough, headache ,chest pain,, palpitations, pain abdomen, burning micturition, increased urination , constipation, loose stools.

PAST HISTORY : 

H/o pain in the upper and lower back since 10yrs but intermittent in type  and not that severe like current condition  and relieved on taking medication and physiotherapy .

No h/o hypertension, DM, asthma, TB, epilepsy , CAD, CVA, thyroid disorders.

PERSONAL HISTORY:

Diet: Mixed

Appetite: Normal

Sleep: Normal

Bowel and bladder movements: Regular

No addictions.

Daily routine:

 She wakes up in the morning around 6.30 am and gets fresh up and  do excercise for 1/2 hr .

7- 9 am : She prepares breakfast and get her son ready for school.

By 10.30 am she goes to school as she is a teacher by profession  and will take classes for students.

1 - 2 pm she will have her lunch and  again  she takes classes upto 4 pm

By 5 pm she reaches home and will do household chores and prepares dinner and will have dinner at around 8pm and goes to bed by 11 pm.

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative and well oriented to time, place and person.

Moderately built and nourished.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema.










VITALS:

Temp:98.4F

PR: 92 bpm

BP: 110/70mm hg

RR:19cpm

SPO2: 97%

Systemic examination:

CVS: s1, s2 heard ,no murmurs.

R/S: 

Upper respiratory tract - normal

Lower respiratory tract-

Inspection:

Chest bilaterally symmetrical,

Shape- elliptical

Trachea- Central

Palpation:

Trachea is Central

Normal chest movements

Vocal fremitus is normal in all areas 

Percussion: in sitting postion

                                  Rt. Lt

Supraclavicular. N(resonant). N

Infraclavicular. N N

Mammary region. N. N

Inframammary region. N. N

Axillary region. N. N

Infra axillary region. N. N

Supra scapular region. N. N

Interscapular region. N. N.  

Infrascapular region. N. N

Auscultation:

Normal vesicular breath sounds

No added sounds

Vocal resonance is normal in all areas.

P/A : Soft, non tender, no organomegaly

CNS:

Higher motor functions - intact

Cranial nerves - intact

Motor system:

           Rt- UL. LL. Lt- UL. LL

Bulk -        N     N.        N. N 

Tone -       N.    N.        N. N

Power -     5/5. 5/5. 5/5. 5/5

Reflexes:                                

                    UL LL

Biceps.       2+. 2+

Triceps.     2+. 2+

Supinator. 2+. 2+

Knee.          2+. 2+

Ankle.        2+. 2+

Sensory system: intact

Co ordination is present

Orthopedic referral I/V/O lower back and upper back pain on 31/12/23



Orthopedic spine surgeon opinion took I/V/O STRUCTURAL SCOLIOSIS on 1/1/24


X RAYS ON 2/1/24

Xray left bending:


XRAY AP VIEW ON RT BENDING


XRAY LATERAL STANDING POSITION


XRAY AP VIEW STANDING POSITION



Orthopaedic referral I/V/O review with reports on 4/1/24


Electronic discharge summary of the patient:





























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