A 32 years old female with lower back ache

32 YEARS OLD FEMALE WITH  LOW BACK ACHE

NOVEMBER 10 th 2022

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CHIEF COMPLAINTS 

Patient came with chief complaints of low back ache since 8 years

 

Bilateral pedal edema on and off since 1 month

Burning micturition since 7 days

Fever since 2 days

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 8 years back then she developed low back pain chronic in onset starting from buttocks and lumbar spine region and radiating up-to head,aggrevates on bending and walking and relieved on medication and lying on prone position .

No history of trauma and no history of urinary incontinence and retention. 

PAST HISTORY 

History of renal calculi 10 years back and used medication for it. 

Underwent Hysterectomy 1year back

Not a known case of HTN, DM, Epilepsy, Asthma, CAD

PERSONAL HISTORY:

Diet- Mixed

Appetite- Normal 

Sleep- Adequate 

Bowel and Bladder movements- Normal(Burning micturition is present) 

FAMILY HISTORY:

No significant family history.

GENERAL EXAMINATION:

No Pallor, Icterus, Clubbing,Cyanosis, Lymphadenopathy, Pedal Edema.

Vitals

Temperature- 97.3F

BP- 110/70mmhg

PR- 62bpm

RR- 16cpm

Spo2- 96%@room air

SYSTEMIC EXAMINATION :

CARDIOVASCULAR SYSTEM:

S1,S2 heard 

No murmurs 

RESPIRATORY SYSTEM:

BAE- present 

No wheeze

Trachea position -Central 

Breath sounds -vesicular

ABDOMINAL EXAMINATION 

 Abdomen is soft and non tender

CNS:

No focal and neurological deficits 

HMF -Normal

Pupils- Bilateral PSNL

                      Upper limb                        Lower limb

               Right             Left                   Right          Left

Tone:      Normal        Normal             Normal       Normal

Power:           5/5           5/5                    5/5              5/5

Reflexes:         Right             Left

Biceps              +                    +

Triceps            +                     +

Supinator         +                    +

Knee                +                   +

Ankle               +                    +

Plantar         Flexion        Flexion

LAB INVESTIGATIONS

HAEMOGRAM 

COMPLETE URINE EXAMINATION 

SERUM CREATININE 

BLOOD UREA

SERUM ELECTROLYTES 

 ECG

ULTRA SOUND REPORT

PROVISIONAL DIAGNOSIS 

Low back ache 

Spondyloarthritis? 

Renal tubular acidosis? 

TREATMENT 

Injection Tramadol 100 mg in 100 my NS IV stat 

Tab .ultra cut 1/2 tab

Monitoring BP, PR, RR, Temperature 6 th hourly