55 F WITH LOW BACK ACHE SINCE 15 YEARS

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CHIEF COMPLAINTS 

55 year old female from Assam came with the CHIEF COMPLAINTS of lower back ache since 15 years .

HISTORY OF  PRESENTING ILLNESS 

Patient is a resident of Assam married at the age of 18 years ,started working in farms 4 years after her marriage ,her work many consisted of ploughing and sowing ,transplanting the sampling requiring her to bend forward and lean for several hours (5-10hrs/day)

She gave birth to her first child 2 years after marriage ,a male child 

2 years after her first child she gave birth to second child ,female 

2 years later she gave birth to her third child,female 

Tubectomised 2 years after last birth 

Underwent hysterectomy 10 years after tubectomy was done due to complaints of amenorrhea 

Patient says she not her cheerful self due to the constant pains since 15 years 

Patient also couldn’t sit outside without a fan even for few minutes ,complaints of hot flashes 

diet -mixed 

Appetite -normal 

Sleep -disturbed due to low back pain 

Bowel and bladder -complaint of urgency 

addictions -started consuming tobacco (tamaka) after her marriage everyday ,in small quantities ,consumes till date .

no known allergies 

TREATMENT HISTORY 

k/c/o HTN since 8 years 

Amlodipine 5 mg OD







SURGICAL HISTORY 

tubectomised 

hysterectomy done 

GENERAL EXAMINATION 

patient is coinscious coherent and co operative 

Well oriented to time ,place ,person 

Moderately built ,moderately nourished 

Pallor -present in the lower palpebral conjunctiva 

Icterus- absent 

Cyanosis -absent 

clubbing -absent 

Lymphadenopathy -absent 

Pedal edema -absent 

VITALS 

TEMP -afebrile 

PULSE RATE -86bpm

PULSE PRESSURE -120/80mmHg

RESPIRATORY RATE -16cpm


SYSTEMIC EXAMINATION:

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



CNS:


Higher mental functions


-Patient is conscious, coherent,co-operative.Oriented to time, place,person.


-Speech = Fluency,comprehension,repetition intact


-Memory =Recent,Remote,Immediate : Intact


Cranial nerve examination -


other cranial nerves are 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 

and minimus 

Gluteus maximus. +5                +5 


Hamstrings           +5                +5 


Quadriceps           +5                +5 


Distal muscles 

Tibialis anterior -Dorsiflexion +5               +5 

Gastrocnemius plantar flexion +5            + 5

Extensor hallucis longus           +5                +5

STRAIGHT LEG RASING TEST 

patient complaints of pain on raising leg 90* on rt and 70 * on left from horizontal 

It is a diffuse type of low back pain ,non radiating with tingling sensation in both the lower limbs more on the left side 

Pain aggravated on Dorsiflexion of foot along with leg raising 

CONTRALATERAL LEG RAISING TEST 

Complaints of pain on both the lower limbs especially in the calf muscles and back on lifting the leg 

REFLEXES
                   Right.              Left

Biceps.       ++                      ++

Triceps.      + +                     ++

Supinator.  + +.                     ++

Knee.          + +.                    ++

Ankle.         + +.                    ++


Plantar.       flexor                  flexor

Plantar reflex 

Sensory examination:



1.Spinothalamic:      R              L

Crude touch            +                +

Pain                         +                +

tingling sensation in both the lower limbs 

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

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 involving the spine ,probably due to degenerative disc pathology probably lumbar spondylosis? (L5-S1) intervertebral disc prolapse?at the level of L5-S1 secondary to early menopause  ?with symptoms suggestive of (traversing nerve )S1 nerve compression ankle reflex -hung up risk factors -occupation required frequent bending forward ,early menopause 

INVESTIGATIONS 
MRI -8 years ago 



IMPRESSION:

Lumbar spondylosis with degenerative disc disease at L3/14 to L5/SI levels showing diffuse disc bulge causing ventral thecal sac indentation at all levels, AP central canal stenosis at L5-SI level. bilateral neural foraminal stenosis at all levels and indentation of right L5 traversing nerve

root.


MRI CERVICAL SPINE

PLAIN


IMPRESSION:

Cervical spondylosis with degenerative disc disease at C5/C6 disc level showing focal left paracentral disc bulge causing ventral thecal sac indentation and impingement of left C6 nerve root at root - exit zone.


MRI day-4 (29-04-2023)










X RAY -26-04-2023(day-1)


On 26-04-2023(day-1)








ORTHOPAEDIC REFFERAL  ON 27-04-2023 (day-1)




Day-1 (27-04-2023)ophthalmology referral 



Day-2 





NEUROSURGERY REFERRAL( day-2 )


Neurosurgeon referral( day -4 ) 30-04-2023


X-RAY day -2(28-04-2023)
X-ray LS SPINE AP VIEW 


X-RAY LS SPINE flexion 

                                                      X-rays LS SPINE in extension 


TREATMENT :

1. TAB. NEUROKIND LC PO/OD

2. TAB. SHELCAL  CT PO/OD

3. TAB. PREGABLIN 75mg PO/HS

4.TAB.AMLODIPINE 5mg PO/OD

FOLLOW UP 

Soap notes 28/04/2023


A 55 years old female with C/O lower back pain since 15years.
C/o Tingling sensation over left lower limb since 4 years
S:
C/o lower back pain decreased compared to yesterday.
Stools Passed

O/E:
Temp- Afebrile 
Bp-120/70mm hg
Pr- 80bpm
Rr-16cpm
Spo2- 98% on RA

General examination: 
Pt is c/c/c
Pallor present
No signs of icterus ,cyanosis,clubbing lymphadenopathy, edema


Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact, NFND
Per abdomen : soft, non tender.
A:
55 years old female with ? Lumbar spondylosis

P: 
TAB. ULTRACET PO/BD
TAB. PAN 40mg PO/OD(BBF)
TAB. NEUROKIND LC PO/OD
TAB. GABA NEURON 100mg PO/HS
TAB . AMLODIPINE 5mg PO/OD
TAB. SHELCAL CT PO/OD

Soap notes (29-04-2023) day -3 

A 55 years old female with C/O lower back pain since 15years.
C/o Tingling sensation over left lower limb since 4 years

S:
C/o lower back pain relieved only on taking medication.
Stools Passed

O/E:
Temp- Afebrile 
Bp-110/70mm hg
Pr- 76bpm
Rr-18cpm
Spo2- 98% on RA

General examination: 
Pt is c/c/c
Pallor present
No signs of icterus ,cyanosis,clubbing lymphadenopathy, edema


Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact, NFND
Per abdomen : soft, non tender.

A:
55 years old female with ?  Lumbar spondylosis

P: 
TAB. ULTRACET PO/BD
TAB. PAN 40mg PO/OD
TAB. NEUROKIND LC PO/OD
TAB. GABA NEURON 100mg PO/HS
TAB . AMLODIPINE 5mg PO/OD
TAB. SHELCAL CT PO/OD

Soap notes
02/05/2023


A 55 years old female with C/O lower back pain since 15years.
C/O Tingling sensation over left lower limb since 4 years

S:
C/O lower back pain relieving a little(25%) on taking medication.
Patient not compliant on NSAID (etoshine mr)due to bloating.


O/E:
Temp- Afebrile 
BP-130/70mm hg
PR-86 bpm
Rr-16 cpm
Spo2- 99% on RA

General examination: 
Pt is c/c/c
Pallor present
No signs of icterus ,cyanosis,clubbing lymphadenopathy, edema


Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact, NFND
Per abdomen : soft, non tender.

A:
55 years old female with ?  Lumbar spondylosis

P: 
TAB. ETOSHINE MR PO/BD
TAB. PAN 40mg PO/OD
TAB. REJUNEX CD3 PO/OD
TAB. PREGALIN-D 75/30 PO/HS (PREGABALIN 75MG+ DULOXITENE 30MG) 
TAB . AMLODIPINE 5mg PO/OD
TAB. SHELCAL CT PO/OD

Soap notes 
3/05/2023

A 55 years old female with C/O lower back pain since 15years.
C/O Tingling sensation over left lower limb since 4 years

S:
C/O lower back pain present same as  to yesterday ,relieved a little on medication 
Stools passed 

O:
Temp- Afebrile 
BP-110/70mm hg
PR-76 bpm
RR-14 cpm
SPO2- 99% on RA

General examination: 
Pt is c/c/c
Pallor present
No signs of icterus ,cyanosis,clubbing lymphadenopathy, edema


Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact, NFND
Per abdomen : soft, non tender.

A:
55 years old female with ?  Lumbar spondylosis

P:
TAB.ULTRACET PO/BD
TAB. PAN 40mg PO/OD
TAB. PREGALIN-D PO/HS (PREGABALIN 75MG+ DULOXITENE 30MG) 
TAB . AMLODIPINE 5mg PO/OD
TAB. SHECAL CT PO/OD
TAB .CLONEZEPAM 0.25mg 
(Of sleep disturbance present ) 
lumbar back support (BECT)

Soap notes 
4/05/2023 

A 55 years old female with C/O lower back pain since 15years.
C/O Tingling sensation over left lower limb since 4 years

S:
Pain reduced 
Stools passed 

O:
Temp- Afebrile 
BP-110/70mm hg
PR-76 bpm
RR-14 cpm
SPO2- 99% on RA

General examination: 
Pt is c/c/c
Pallor present
No signs of icterus ,cyanosis,clubbing lymphadenopathy, edema


Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact, NFND
Per abdomen : soft, non tender.

A:
55 years old female with ?  Lumbar spondylosis

P:
TAB.ULTRACET PO/BD
TAB. PAN 40mg PO/OD
TAB. PREGALIN-D PO/HS (PREGABALIN 75MG+ DULOXITENE 30MG) 
TAB . AMLODIPINE 5mg PO/OD
TAB. SHECAL CT PO/OD
TAB .CLONEZEPAM 0.25mg 
(Of sleep disturbance present ) 
lumbar back support (BECT)

Soap notes
05/05/2023


A 55 years old female with C/O lower back pain since 15years.
C/O Tingling sensation over left lower limb since 4 years

S:
C/O lower back pain decreased compared to yesterday 
Stools passed 

O:
Temp- Afebrile 
BP-110/70mm hg
PR-76 bpm
RR-14 cpm
SPO2- 99% on RA

General examination: 
Pt is c/c/c
Pallor present
No signs of icterus ,cyanosis,clubbing lymphadenopathy, edema


Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact, NFND
Per abdomen : soft, non tender.

A:
55 years old female with ?  Lumbar spondylosis

P:
TAB.ULTRACET PO/BD
TAB. PAN 40mg PO/OD
TAB. PREGALIN-D PO/HS (PREGABALIN 75MG+ DULOXITENE 30MG) 
TAB . AMLODIPINE 5mg PO/OD


PSYCHIATRIC REFERRAL (30/04/2023)

This is a case of a 53-year-old female with lumbar spondylosis. The patient is having sleep disturbances and is taking tablet HICLAM plus since five years for sleep at bedtime. The patient is habituated to take medications frequently for unknown complaints. Patient is referred to us in view of further evaluation, 

history of presenting illness, 

patient was apparently alright around 15 to 20 years ago, then one fine day, she noticed having constant back pain (lower) and with passing of time the pain progressed to left leg up two left feet. She complained of pain and tingling sensation. then she consulted a doctor, who, after various investigations told the patient that her vertebral column (lower back, vertebra-lumbar ) changes were seen and heard. Changes were seen and were kgetting compressed Thus  the pain was seen and is radiating to her. Lower back. She was given treatment, along with painkillers. Since then she is consuming painkillers almost daily. She has sleep disturbances (initiation of sleep) due to her lower back pain but is fine once she sleeps. She used to do farming work then, and used to go to the work and daily.

For the next 4 to 5 years, she consulted various doctors to relieve her pain and for better treatment. In this period, she started complaining pain in the upper back (both sides), neck, pain over the face (bilaterally), bilateral eye pain, swollen eyes, headache, tingling, sensation, overhead/scalp, unilateral or bilateral headaches of various intensities , sometimes she complained of having something in her head (she had the sensations) she consulted a neurosurgeon for the said complaints, 10 to 11 years ago, after multiple test, including CT scan done, according to the, OD.

Doctors told them that changes were seen in the CT scan and that some problem was there. And since then she was started on tablet HICALM plus along with her previous medications, for lower back pain. This tablet also help her with her sleep disturbances. She is able to sleep better with that tablet so she started using tablet. HICALM plus daily since 10 to 11 years. 

She later consulted various doctors (more than 10) in the last 10 to 15 years as her complaints didn’t subside and no treatment was relieving Herpen totally, and that no doctor was finding the cause. She tried various medications, and she is tensed if she is not taking any medication. If she doesn’t replenish her medications once when over, then she misses taking tablets for few days. She feels tensed and irritable and busters her family to get the tablets as soon as possible.She feels that she needs medicine to live a proper life every day as medicines, relieve her of pain, and she feels better. She stopped working as farmer-made since last five years, due to  pains and also financial stability-support given by her children. She does daily chores in her house, self care and hygiene. Maintained . Appetite is normal. She is currently using tablet ETORICOXIB, NEXPRORD, tablet, SULSASALAZINE, tablet HICALM plus, 

She can’t sit for long time due to the pain, physical/mental stress. Is increasing her pain sensation. She doesn’t have any relieving factors for her pain other than medications, she constantly thinks about her health, her pains, that she is not able to have a normal life like others, her age due to the pain. She feels low regarding her condition since past 10 years, and she has become less energetic and feels her body has become fragile. She constantly also thinks about her family members, since last 5 to 6 years, she is not able to tolerate loud noises, she gets sick and her pains increase when exposed to loud Noises, no history of head, injury, seizures, 

no history of substance, abuse, 

no history of hearing of voices, says, talking, self, smiling behaviour, 

no history of suicide, ability, 

no history of grandiosity, flight of ideas, no history of fear, impending, doom, palpitations, 

no history of repetitive thoughts, actions



Past history-

known case of hypertension. Since 10 years uses tablet amlodipine



Family history-

no psychiatric history in the family



On examination

BP-110/70, mmHg

Pulse rate-84 beats per minute

Respiratory rate-19/minutes

Temperature-a febrile



Patient is unable to sit on the chair comfortably for longer duration (more than 10 minutes) due to lower back pain. Patient is moderately built well-kept and responding well to oral commands.

ETEC + and sustained

PMA-normal 

Rapport established

RT-normal relevant and coherent

Speech-T ,V,R-normal

Thoughts-constantly things about her pain

Mood-‘dare hai” Lekin accha hai 

Effect-Euthymic 

Perception-NAD

Oriented to time, place and person



IMPRESSION -1) persistent somatoform disorder in background of physical illness

2)mild  depressive episode



PLAN 


1. O D. PSYCHO EDUCATED

2. TAB  PREGABLIN plus duloxetine, 30 mg.(PREGALIN-D-30).

3. TAB clonazepam 0.25mg/po/(if sleep disturbances present)

4. Stop T. HICALM plus.


PSYCHIATRIC FOLLOW UP  (1/05/2023)



Patient is seen complaint on medication took night dose of medication, of medication

Reports to have slept well last night (9:30 PM to 5 AM) 

Appetite is normal 

No fresh complaints 

Patient is sitting on the bed in uncomfortable way as she has back pain. Responding well to oral commands. 

ERC +, maintaineded

P M. A-normal

Speech, T, R normal. 

R T.-NORMAL, RELEVANT AND COHERENT

THOUGHT-ABOUT HER HEALTH

WORD-‘ACHA HAI’  

AFFECT-EUTHYMIC

PERCEPTION, NAD

ORIENTED TO TIME, PLACE, PERSON

1) patient and OD counselled 

2) continue medications by neurosurgeon. (gabapentin, duloxetine )


With hold TAB. Pregalin-D


PSYCHIATRY, FOLLOW-UP NOTES (2/05/2023)



Patient seen complaint on medication, but took psychiatric medication along with neurosurgery medication (psychiatry, medication was stopped yesterday) 

Reports to have slept well last night 

Appetite-normal 

No fresh complaints

Patient and O D. Strictly counselled to follow treatment accordingly as per plan. 

MSE : GAB: patient is sitting on the chair uncomfortably. Due to her back pain, responds well to oral commands.

ETEC +, sustained 

P M.A-normal. 

Speech-TV R. Normal 

RT-normal relevant and coherent 

Thought-about her operation Food issue (north, South difference)

Mood-Accha Hai 

Affect- Euthymic


Perception-NAD 



PSYCHIATRY s, FOLLOW-UP NOTES (3/05/2023)

Patient seen complaint on medication 

Took night doors of medication 

Report to have slept well last night 

Appetite-Normal

No fresh complaints 

MSE-patient is sitting on the bed and responding to oral commands 

ETEC-present 

P M. A-Normal

Speech-TVR-Normal

RT-normal relevant and coherent 

Thought-worried about her health 

Mood-Accha Hai 

Affect- Euthymic

Perception-NAD 

Oriented to time, place and person 

DISCHARGE SUMMARY 



Final diagnosis 



DISCHARGE SUMMARY 



Final diagnosis 



Low backache 15 years 



Headache 5 years 



IMPRESSION -




1) persistent somatoform disorder in background of physical illness



2)mild  depressive episode



3)Hypertension 10 years



A 55 years old female with C/O lower back pain since 15years.


C/O Tingling sensation over left lower limb since 4 years


patient was married at the age of 18 years ,non consanguineous marriage,she did not receive any form of education ,started working in the farms 4 years after her marriage involving ploughing and sowing ,transplanting the sampling requiring her to bend foward and lean for several hours (5-10hrs/day)




She was apparently asymptomatic 15 years back when she developed low back ache ,which was insidious in onset and gradually progressive , radiating type ,to both the lower limbs more on left side ,more in the calf muscles ,associated with tingling and numbness more the the right side .Pain aggravates on sitting ,she is unable to sit for long durations




PAST HISTORY 


K/c/o of Hypertension since 10 years 


k/c/o cervical spondylisis since 8 years


COURSE IN HOSPITAL


Patient was investigated further and was found to have persistent somatoform disorder in background of physical illness with mild  depressive episode,patient and OD were pyscho educated 


Patient was reffered to opthalomogy department to rule out  hypertensive retinopathy ,patient didn’t show any signs of following .


Patient on referral to neurosurgery was prescribed TAB. PREGALIN-D PO/HS (PREGABALIN 75MG+ DULOXITENE 30MG) ,lumbar back support belt 


Advice surgery L4-L5 L5-S1 laminectomy and  discectomy 


patient and OD counselled to continue medications by neurosurgeon. (gabapentin, duloxetine )




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