A 48 yr old female with low back ache

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-centred online learning portfolio and your valuable comments on comment box is welcome. I've 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 a diagnosis and treatment plan. 

HOPI-

Patient was apparently asymptomatic 25 years ago then she developed pain from back of neck to lower back throughout the day aggregated by work and relieved by rest. Apparently the pain started post child birth.

16 years ago she went to hospital and was advised exercise but it did not relieve.

She developed itchy lesions all over body from the past 2 to 3months

After squatting and when she gets up she has syncopal attack

Past history -

Known case of hypothyroidism and using thyroxine since 2015

Known case of hypertension and using telme from 2015

In 2016 she got gall stones and cholecystectomy was done

Family history -

Her mother and daughter also have same complaint 

Personal history - 

Diet - mixed 

Appetite - decreased

Sleep - disturbed

Bowl and bladder - regular

Addiction - tobacco pan everyday since 15 year

No allergy 

General examination -

patient is coinscious coherent and co operative 

Well oriented to time ,place ,person 

Moderately built ,moderately nourished 

Pallor -absent 

Icterus- absent 

Cyanosis -absent 

clubbing -absent 

Lymphadenopathy -absent 

Pedal edema -absent 

VITALS 

TEMP -afebrile 

PULSE RATE -86bpm

PULSE PRESSURE -128/90

RESPIRATORY RATE -16cpm 

SYSTEMIC EXAMINATION 

CNS EXAMINATION

HIGHER MENTAL FUNCTIONS:

Conscious, oriented to time place and person.

-Speech =Fluency,comprehension,repetition intact

-Memory =Recent,Remote,Immediate : Intact

CRANIAL NERVE EXAMINATION:

1st : Normal

2nd : visual acuity is normal

3rd,4th,6th : pupillary reflexes present.

                   EOM full range of motion present

5th : sensory intact

                      motor intact

7th : normal

8th : No abnormality noted.

9th,10th : palatal movements present and equal.

11th,12th : normal.

Motor examination :-

Bulk of muscle normal on both sides on inspection

Tone -

                        Right. Left 

Upper limb. Normal. Normal

Lower limb. Normal. Normal

POWER-

upper limbs +5 in all proximal and distal muscles 

Lower limbs -

                        Rt LT 

Iliopsoas- +5 +5 

Adductor femoris +5 +5 

Gluteus medius +5 +5

Gluteus maximus. +5 +5 

Hamstrings +5 +5 

Quadriceps +5 +5

Tibialis anterior - +5 +5

Gastrocnemius +5 + 5

Extensor hallucis longus. +5. +5

REFLEXES-

                   Right. Left

Biceps. ++ ++

Triceps. + + ++

Supinator. + +. ++

Knee. + +. ++

Ankle. + +. ++

Sensory examination:

1.Spinothalamic: R L

Crude touch + +

Pain ++

2.Posterior column:

Fine touch + +

Vibration Normal 

Position sense- normal 

3.Cortical

Stereognosis: + +

Graphesthesia +. +

CEREBELLUM:

Finger nose and finger finger test were normal

No dyadiadokokinesia 

No pendular knee jerk

Heel knee test : normal

Spine examination: -

No spine tenderness 

Straight leg raising test- positive pain at 70° angle

Before-15cm 

After bending-22cm

CVS:

Elliptical & bilaterally symmetrical chest

-No visible pulsations/engorged veins on the chest

-Apex beat seen in 5th intercostal space medial to mid clavicular line

-S1 S2 heard

-No murmurs

RESPIRATORY SYSTEM:

Upper respiratory tract normal

  Lower respiratory tract :

-Trachea is central

-Movements are equal on both sides

-On percussion resonant on all areas

-Bilateral air entry equal

-Normal vesicular breath sounds heard

-No added sounds

-Vocal resonance equal on both sides in all areas.

PER ABDOMEN EXAMINATION --

Scaphoid

-No visible pulsations/engorged veins/sinuses

-Soft,non tender, no guarding and rigidity, no organomegaly

-Bowel sounds heard

PROVISIONAL DIAGNOSIS:-

This is a case of lower back ache probably due to neural pain