33 year old female

 A 33 year old female came to the OPD with chief complaints of pain in the left lateral region of leg and gluteal region since four months.

Patient was apparently asymptomatic four years ago and developed pain in the left lateral region sudden in onset burning type and continuous which relieved on medication and lying down and aggravated on walking associated with radiation of pain to the left hip region after 5 days.

She went to a hospital and used medication for 9 months and since then she had no complaint of pain.6 months ago she again developed sudden in onset progressive burning type of pain in lateral region of left leg and gluteal region which aggravated on walking and relieved on lying down.

PAST HISTORY :

No h/o HTN ,DM , EPILEPSY , CVA , CAD , TB


FAMILY HISTORY : NAD


PERSONAL HISTORY : 

Diet - vegeterian

Appetite - normal

Bowel & Bladder - Regular

Sleep - Adequate

Addictions - betalnut


GENERAL EXAMINATION :

No Pallor , Icterus , Cyanosis , Clubbing , Lymphadenopathy


VITALS :

PR - 78 bpm

BP - 110/80 mmhg

RR - 18 cpm


SYSTEMIC EXAMINATION :


 Liver and spleen not palpable

CNS Examination :



Mini mental state examination : 25/25

Higher mental function : normal

Speech : normal

Spine : no deformities and tenderness

Cranial nerve : intact

Tone : upper limb right and left normal,lower limb right and left normal

Power:. Right left

U/L : shoulder - 4+/5,4+/5

Abduction and adduction - 4+/5,4+/5

Flexion and extension - 4+/5,4+/5

Elbow : flexion and extension : 4+/5,4+/5

Pronation and supination - 4+/5,4+/5

Hip : flexion and extension 4+/5,4+/5

Adbuction and adduction - 4+/5,4+/5

Knee: flexion and extension - 4+/5,4+/5

Ankle : dorsiflexion - 4/5,3+/5

Plantar flexion - 4+/5 ,4+/5

Fine touch : 

Upper limb - normal(right),normal(left)

Lower limb -100%(right) , 50% decreased in left lateral region,L5,S1 dermatomes of leg(left)

Pain : 

Upper limb - normal (right), normal (left)

Lower limb - normal (right), decreased on medial aspect of sole(left)

Temperature:

Upper limb - normal(right),normal(left)

Lower limb- normal (right),normal(left)

Vibration:

Upper limb - normal (right),normal (left)

Lower limb - normal (right),normal(left)

Propioception : normal

Deep tendon reflexes :

Biceps- +

Triceps- +

Brachioradialis- +

Patellar- +

Ankle - +

Investigations:

Xray :



ECG :

Mri :
















Provisional diagnosis :
?L4 L5 disc prolapse


Comments

Post a Comment

Popular posts from this blog

A 50 year old male

Image
 This is a case of a 50 year old male who is a farmer by occupation used to work for 4-5 hours daily and got involved in heavy work like lifting heavy objects for 6 months after which he was asymptomatic for 2 months and later developed pain in the left hip and left leg region since 4 months pain is progressive burning type of pain radiating from hip region to leg which aggravates on walking for short distance like 100 metres after which he rests for 10 mins by standing in flexion position and the pain is relieved on posturing like knee elbow position and bending position and some injections by which he got relief for 9 days. No difficulty in getting up from squatting position,no difficulty in rolling on bed,no sensory disturbance,no bowel and bladder involvement PAST HISTORY  : history of fall from a tree height about 10 feet 15 years ago. No h/o HTN ,DM , EPILEPSY , CVA , CAD , TB FAMILY HISTORY : NAD PERSONAL HISTORY :  Diet - vegeterian Appetite - normal Bowel & Bladder - Regul
Read more

1601006049 - multiple liver abscess with right sided pleural effusion

Image
 1601006049 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 E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment April 25th,2021 Hall ticket number : 1601006049 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 E log book also reflects my patie
Read more