A 41Y M resident of west Bengal came to the opd with the c/o difficulty in walking due to pain in lower back since 1 year.
General medicine
~Case Discussion
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A 41 year male resident of west Bengal came to the opd of General Medicine with :
C/o :Difficulty in walking due to pain in lower back since 1 year.
History of Presenting illness : Apparently the patient was asymptomatic 1 year ago later he met with a bike accident and felt severe pain in the lower back region and also heard a clicking sound while lifting the bike.
Pain was sudden in onset, gradual in progression, radiating to thighs and was of burning type which is aggravated on walking or any other movements and relieved on resting on right side.
The MRI shows herniation of vertebral discs into the cauda equina.
Negative history: No history of fever
No history of inflammation No history of redness
No history of morning stiffness
Past history: At the age of 15 years had similar back ache while lifting heavy weights which was relieved on medication
Has underwent appendectomy 1 year ago.
Personal History: Normal appetite, Inadequate sleep (2-3 hours per day)
since 1 year due to pain,
Burning micturition since 1 year,
Difficulty in defecation since 1 year.
He is a chronic smoker, smokes about 10 - 12 cigarettes per day for almost
30 years.
General Examination:
The patient was conscious, coherent, cooperative and well aware of surrounding place and time.
He has no pallor, icterus, cyanosis, clubbing, and no generalized lymphadenopathy, edema, koilonychia.
Vitals :
Pulse rate : 72 beats per min
Respiratory rate : 16 cycles per min
Blood pressure: 120/80 mm of Hg
Temperature: Afebrile
Systemic examination:
Respiratory system:
Inspection-
Respiratory Rate :18 cycles per min, normal rhythm, Normal Shape and bilaterally symmetrical chest, normal nose, midline trachea.
Palpation -
Confirmation of respiratory moments
Position of Mediastinum is midline
No tenderness is present in the chest.
Percussion –
Normal Resonant sounds are felt
Cardiac dullness - normal
Liver dullness - normal
Auscultation -
Breath sounds are Vesicular
Cardiovascular System - Pulse rate: 73 beats per minute
Rhythm: Regular
Volume:Normal
Character: Normal
Blood pressure : 120/80 mm of Hg
Inspection -
Chest Wall shape Normal and bilaterally symmetrical, Apex beat is seen on 5th intercoastal space, normal pulsations are seen.
Palpation: Inspection findings are confirmed
Percussion -
Dull note: Normal
Auscultation -
Heart sounds:
1st - heard, and normal, 2nd - heard, and normal
Gastrointestinal System/Per-abdominal Examination -
Oral Cavity -
Lips — Fissure: Absent
Cracks : Absent
Discoloration : Absent
Teeth : Normal
Tongue — Coating:Absent
Fasciculation : Absent
Cracks : Absent
Tonsils —Normal
Per Abdomen -
Inspection -
Shape - Normal
Movements with respiration : Normal
Umbilicus - Inverted
Palpation -
Liver - Normal
Spleen - Normal
Swelling - Absent
Rebound tenderness - Absent
Percussion - Free fluid Absent
Auscultation-Peristaltic sounds - Present
Central nervous system -
Mental Status: The patient was conscious, coherent, cooperative and well aware of surrounding place and time
Speech: Normal
General behaviour :Normal
Motor system -
No Involuntary Movement are present
Sensory System -
RUL. LUL. LUL. LLL.
Touch -
Fine touch. + + + +
Crude touch. + + + +
Pressure. + + + +
Pain. + + + +
Vibration. + + + +
Stereognosis. + + 0. 0
Motor System -
Inspection - Normal contour
Bulk of muscle - decreased in lower limbs
Tone of muscle - decreased in left lower limb
Strength of the muscles -
Right. Left
Biceps. 5. 5
Triceps 5. 5
Extensors of thigh. 5. 1
Flexors of thigh. 5. 1
Gait : Antalgic gait
Reflexs -
Right. Left
Plantar reflex. Mute. Mute
Ankle jerk. 1/5. Mute
Biceps jerk. 5. 5
Triceps jerk. 5. 5
Knee jerk. 5. 5
Corneal reflex. Present. Present
Pupillary reflex
Direct. Present. Present
Indirect. Present Present I.Investigation Advised -
MRI
Rx:
Surgical correction by laminectomy.
Treatment history:
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