36y/M
A 36 year old male farmer by occupation came with chief complaints of low back ache radiating to right lower limb since 11 months
HISTORY OF PRESENT ILLNESS AND PAST HISTORY :
Patient was apparently asymptomatic 5 years back then he developed pain in the the lower back radiating to right lower limb with associated calf pain which was aggravated on walking and relieved on rest, for which he was taken to the local hospital, the pain was subsided on taking the medicine prescribed by the local practitioner.
He had a similar acute attack few days after, which was severe so much so that he wasn't able to get out of bed, he was taken to local hospital and treated symptomatically.
He had similar kind of episodes, 3-4 times an year. The pain was subsided to an extent by taking medication but never totally relieved. The patient's attender claims that frequency and severity of pain was more during winter season.
In March 2020, he was admitted to KIMS with similar complaints. Patient has surgery done in March 2020(L5-S1 PSF + Transforaminal interbody fusion L4 L5 fenestration discectomy on left side).
Patient was asymptomatic 10 months post operation. Then he developed body pains after doing some kind of manual work, for which he asked his son to walk on his spine to relieve the pain. But it resulted in another acute back ache, for which he was admitted in KIMS.
On 31-12-20 L5-S1 PSF + L4 fenestration L5 right hemi laminectomy + L5 sequestered discectomy.
The patient still had c/o pain post operation but of less severity which gradually progressed to the current state.
Not a k/c/o HTN/DM/TB/CAD/epilepsy.
PERSONAL HISTORY :
APPETITE -normal
Sleep adequate
Bowel and bladder -regular
Smoking - 6 cigarettes /day
FAMILY HISTORY :
not significant
Examination :
Patient is c/c/c.
Temp: Afebrile
PR:72bpm
Rr:16cpm
Bp:120/80 mm of Hg
Grbs:162
No pallor, icterus, cyanosis, clubbing, lymphadenopathy,edema
Cvs:S1,S2 heard
Respiratory : BAE present.
Abdomen:scaphoid,no tenderness, free fluid, palpable mass, hernial orifices, bowel sounds heard.
CNS :conscious,speech normal, reflexes normal.
PROVISIONAL DIAGNOSIS :
Recurrent L5 S1 paracentral disc extrusion with discitis with right L4-L5 central disc extrusion with S1 lumburization.
FEVER CHART :
REFFERED TO ORTHO I/V/O BACK ACHE RADIATING TO RIGHT LOWER LIMB:
INVESTIGATIONS ;
1. ECG;
2. HEMOGRAM;
3.SERUM ELECTROLYTES;
4.SERUM CREATININE;
5. BLOOD UREA;
6. X RAY
TREATMENT
Ward:
Soap notes :
01/09/21
36Y Old male with c/o of lower back ache since 11 months, radiating to Right lower limb.
Subjective : C/O Lower back ache radiating to Rt. Lower Limb.
Objective :
Afebrile
PR : 70 BPM.
BP : 110/80mm of Hg
RS : BAE +
CVS : S1, S2 +
Spinal tenderness : + at L5 - S1
Assessment :
Recurrent L5 - S1 paracentral disc extrusion with discitis with Rt. L4 - L5 central disc extrusion with S1 Lumbarization
Plan of care :
1. Inj. OPTINEURON 1 amp in 100ml ND/IV/OD
2. 2. T. Ultracet 1/2 tab PO/QID
3. 1/2 - 1/2 - 1/2 - 1/2
4. Pregabalin- M/ 75 mg PO/BD
8pm- x - 8 pm
5. Nebulization with 2 respules of Salbutamol 8th Hrly
Ward:
Soap notes :
02/09/21
36Y Old male with c/o of lower back ache since 11 months, radiating to Right lower limb.
Subjective : C/O Lower back ache radiating to Rt. Lower Limb. ( Decreasing)
Objective :
Afebrile
PR : 74 BPM.
BP : 110/70 mm of Hg
RS : BAE +
CVS : S1, S2 +
Spinal tenderness : + at L5 - S1
Assessment :
Recurrent L5 - S1 paracentral disc extrusion with discitis with Rt. L4 - L5 central disc extrusion with S1 Lumbarization
Plan of care :
1. Inj. OPTINEURON 1 amp in 100ml ND/IV/OD
2. 2. T. Ultracet 1/2 tab PO/QID
3. 1/2 - 1/2 - 1/2 - 1/2
4. Pregabalin- M/ 75 mg PO/BD
8pm- x - 8 pm
Ward:
Soap notes :
03/09/21
36Y Old male with c/o of lower back ache since 11 months, radiating to Right lower limb.
Subjective : C/O Lower back ache radiating to Rt. Lower Limb. ( Decreasing)
Objective :
Afebrile
PR : 72 BPM.
BP : 110/70 mm of Hg
RS : BAE +
CVS : S1, S2 +
Spinal tenderness : + at L5 - S1
Assessment :
Recurrent L5 - S1 paracentral disc extrusion with discitis with Rt. L4 - L5 central disc extrusion with S1 Lumbarization
Plan of care :
1. Inj. OPTINEURON 1 amp in 100ml ND/IV/OD
2. 2. T. Ultracet 1/2 tab PO/QID
3. 1/2 - 1/2 - 1/2 - 1/2
4. Pregabalin- M/ 75 mg PO/BD
8pm- x - 8 pm
Ward:
Soap notes :
04/09/21
36Y Old male with c/o of lower back ache since 11 months, radiating to Right lower limb.
Subjective : C/O Lower back ache radiating to Rt. Lower Limb. ( Subsiding)
Objective :
Afebrile
PR : 72 BPM.
BP : 110/70 mm of Hg
RS : BAE +
CVS : S1, S2 +
Spinal tenderness : + at L5 - S1
Assessment :
Recurrent L5 - S1 paracentral disc extrusion with discitis with Rt. L4 - L5 central disc extrusion with S1 Lumbarization
Plan of care :
1. Inj. OPTINEURON 1 amp in 100ml ND/IV/OD
2. 2. T. Ultracet 1/2 tab PO/QID
3. 1/2 - 1/2 - 1/2 - 1/2
4. Pregabalin- M/ 75 mg PO/BD
8pm- x - 8 pm
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