80 YR OLD FEMALE WITH LOWER BACKACHE AND BURNING SENSATION OF BOTH UPPER AND LOWER LIMBS

202323120 janamma
CASE HISTORY AND CLINICAL FINDINGS
CHIEF COMPLAINTS
C/O LOWERBACKACHE SINCE 5 MONTHS
C/O BURNING SENSATION OF BOTH UPPER LIMB AND LOWER LIMB SINCE 5 MONTHS
C/O FEVER SINCE 10 DAYS
C/O PAIN DURING DEFECATION SINCE 5 MONTHS
HOPI
PATIENT WAS APPRENTLY ASYMPTOMATIC 5 MONTHS BACK THEN HE DEVELOPED LOWER
BACKPAIN , INSIDIOUS IN ONSET , GRADUALLY PROGRESSIVE AGREVATED ON BENDING
,RELIEVED ON MEDICATION
C/O BURNING SENSATION OF BOTH UPPER LIMB AND LOWER LIMB SINCE 5 MONTHS NOT
ASSOCIATED WITH ANY TINGLING AND NUMBNESS OF THE LIMBS.
C/O OF FEVER LOW GRADE SINCE 10 DAYS , NOT ASSOCIATED WITH CHILLS AND
RIGOR,ON AND OFF ,NO COUGH AND COLD
C/O BURNING MICTURATION SINCE 5 TO 6 MONTHS ,NO INCREASED IN FREQUENCY , NO
HESITANCY,NO COMPLAINTS OF DECREASED URINE OUTPUT
NOCTURIA + , NO C/O OF POLYPHAGIA , NO POLYDYPSIA
C/O OF PAIN DURING DEFECATION SINCE 5 MONTHS, NON BLOOD STAINED STOOLS , NO
TENESMUS
DECREASED APPETITE HISTORY OF WEIGHT LOSS
PAST HISTORY
N/K/C/O DM,HTN,EPILEPSY,CVA,CAD,TB,ASTHMA,THYRIOD DISORDERS
PERSONAL HISTORY:
DIET-MIXED
APPETITE -NORMAL
BOWEL AND BLADDER - DECREASED URINE OUTPUT
SLEEP-ADEQUATE
ADDICTIONS- NONE
ALLERGIES- NONE
FAMILY HISTORY:
INSIGNIFICANT
GENERAL EXAMINATION:
PATIENT IS CONSIOUS ,COHERENT ,COPERATIVE
NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY
VITALS:
TEMP-96.6F
BP- 120/70MMHG
PR-80BPM
RR-18CPM
SPO2-99% AT ROOM AIR
SYSTEMIC EXAMINATION:
CVS-S1 S2 HEARD NO MURMURS
RS-BAE +,NVBS
CNS-NFND
P/A -SOFT, NON TENDER
COURSE IN THE HOSPITAL
PRESENTED TO THE OPD ON 26-05-2023 WITH COMPLAINTS OF
C/O LOWERBACKACHE SINCE 5 MONTHS
C/O BURNING SENSATION OF BOTH UPPER LIMB AND LOWER LIMB SINCE 5 MONTHS
C/O FEVER SINCE 10 DAYS
C/O PAIN DURING DEFECATION SINCE 5 MONTHS
26/5/23
HEMOGRAM
HAEMOGLOBIN :10.1 gm/dlTOTAL COUNT 7800 cells/cumm PLATELET COUNT 3.00lakhs/cu.mm
28/5/23
HEMOGRAM
HB- 10.1
TLC - 7,800
PCV-30.8
MCV-76.2
MCHC-33.0
PLT-3.08
29/05/23
HEMOGRAM
HB- 11.0
TLC - 10,100
PLT-1.50
30/5/23
HEMOGRAM
HB 10.2
TLC 9100
PLT 3.13
31/5/23
HEMOGRAM
HB 10.7
TLC 9900
MCV 78.7
MCHC 31.8
PLT 3.59
1/6/23
HEMOGRAM
HB 10.3
TLC 10800
MCV 80.3
MCHC 31.9
PLT 2.71
USG IMPRESSION: 26/5/23
RIGHT GRADE 1 RPD CHANGES
LEFT GRADE 2RPD CHANGES
CORRELATE WITH RFT
INTERNAL ECHOS IN URINARY BLADDER ?CYSTITIS
CORRELATE WITH CUE
2D ECHO IMPRESSION :26/5/23
EF-65
TRIVIAL TR+ , AR+,NO MR
NO RWMA ,NO AS/MS
SCLEROTIC AV
GOOD LV SYSTOLIC FUNCTION
DIASTOLIC FUNCTION +
NO PAH/PE
SURGERY REFERRAL DONE ON 27/5/23
ADVICE
1. NO ACTIVE SURGICAL INTERVENTION I/V/O RECTAL PROLAPSE
2. HIGH FIBRE DIET
3. AVOID EXERCISING
4. OINT. SMUTH FOR L/A BEFORE DEFCATION
SYP. CREMAFIN 30ML PO/HS
ORTHO REFERRAL DONE ON 29/5/23
ADVICE
1. TAB ULTRACET PO/BD X 5 DAYS
2. T.PAN 40 MG PO/BD X 5 DAYS
3. T.SHELCAL CT PO/OD X 30 DAYS
4. T.NEUROKIND LC PO/OD X 15 DAYS
5. T. VITAMIN D3 50,000 UNITS ONCE A WEEK FOR 4 WEEKS
6. PHYSIOTHERAPY 1 FT BACK DAILY
Investigation
26/5/23
HEMOGRAM
HAEMOGLOBIN :10.1 gm/dlTOTAL COUNT 7800 cells/cumm PLATELET COUNT 3.00lakhs/cu.mm
28/5/23
HEMOGRAM
HB- 10.1
TLC - 7,800
PCV-30.8
MCV-76.2
MCHC-33.0
PLT-3.08
29/05/23
HEMOGRAM
HB- 11.0
TLC - 10,100
PLT-1.50
30/5/23
HEMOGRAM
HB 10.2
TLC 9100
PLT 3.13
31/5/23
HEMOGRAM
HB 10.7
TLC 9900
MCV 78.7
MCHC 31.8
PLT 3.59
1/6/23
HEMOGRAM
HB 10.3
TLC 10800
MCV 80.3
MCHC 31.9
PLT 2.71
USG IMPRESSION: 26/5/23
RIGHT GRADE 1 RPD CHANGES
LEFT GRADE 2RPD CHANGES
CORRELATE WITH RFT
INTERNAL ECHOS IN URINARY BLADDER ?CYSTITIS
CORRELATE WITH CUE
2D ECHO IMPRESSION :26/5/23
EF-65
TRIVIAL TR+ , AR+,NO MR
NO RWMA ,NO AS/MS
SCLEROTIC AV
GOOD LV SYSTOLIC FUNCTION
DIASTOLIC FUNCTION +
NO PAH/PE
DIAGNOSIS
LUMBAR SPONDYLOSIS WITH?PERIPHERAL NEUROPATHY WITH MILD RECTAL PROLAPSE
WITH CKD [STAGE 4] WITH DENOVO T2DM WITH UNCONTROLLED SUGARS (RESOLVED)
TREATMENT GIVEN
IV.NS,RL AT 50 ML /HR
INJ.LASIX 40MG
SYP.CREMAFIN 15ML PO/TID
OINTMENT SMUTH L/A BEFORE DEFECATION
T.NODOSIS 500MG PO/BD
INJ.HAI INFUSION AT 2ML/HR
INJ.NPH SC BD ACCORDING TO GRBS
ADVICE AT DISCHARGE
SALT RESTRICTION 2GM/DAY
FLUID RESTRICTION 1.5 LIT/DAY
INJ.HAI 8U SC TID PREMEAL 15 MINS BEFORE FOOD
INJ.NPH 6U BD PREMEAL 15 MINS BEFORE FOOD
T.NODOSIS 500MG PO/BD
T.OROFER XT PO/OD
T.LASIX 40 MG PO/BD
T.SHELCAL PO/OD
SYP.CREMAFIN 15 ML PO/TID
OINTMENT SMUTH FOR LOCAL APPLICATION BEFORE DEFECATION
WATCH OUT FOR HYPOGLYCEMIC SYMPTOMS SUCH AS
PALPITATIONS,GIDDINESS,SWEATING TACHYPNOEA



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