A 72 YR OLD FEMALE WITH CERVICAL & LUMBAR SPONDYLOSIS

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I am Nomika Alli (Roll no 179) of 6th Sem MBBS.

A 72 yr old female came to OPD on 14-12-2022 8 pm with c/o low backache radiating to both legs and neck pain since 1 yr with generalized body pains and tingling sensation & numbness of both UL & LL since 6 months .

HISTORY OF PRESENT ILLNESS: 

This patient is a 72 yr old female , housewife by occupation apparently asymptomatic 1 yr back and developed lower back pain radiating to B/L LL and neck pain since 1 yr which is non radiating spinal tenderness. 

All throughout her illness the patient was able to carry on with her daily activities. Her daily routine is waking up at 6 am in the morning, drinking tea at 7:00 am , having her breakfast as rice at 9 am. She is going to have her lunch as rice with curry at 1 pm . She used to have tea at 5:00 pm and her dinner as rice with curry at 8 pm. She goes asleep by 9 pm.  

HISTORY OF PAST ILLNESS:

K/C/O HTN since 15 yrs ( on tab TELMA H PO/OD takes regularly)

N/K/C/O DM/ asthma/ TB/epilepsy/ CAD

SURGICAL HISTORY: 

Cataract surgeries to rt. eye 5 yrs back & lt. eye 4 yrs back

Tubectomy 45 yrs back  

no blood transfusions

PERSONAL HISTORY:

1. Married 
2. Takes mixed diet.
3. appetite normal
4. Regular bowel and bladder movements
5. No known allergies.
6. no addictions

FAMILY HISTORY: 

n/k/c/o DM, HTN, Heart disease, asthma, stroke, cancers, any hereditary disease.

OBSTETRIC HISTORY: G4P4L4

 Age at marriage:  15yrs

Gravida: 4

para: 4 

no. of living children: 4

Family planning: permanent sterilization (tubectomy 45 yrs back)

BIRTH HISTORY:

1st pregnancy: NVD

2nd pregnancy: NVD

3rd pregnancy: NVD

4th pregnancy: NVD

GENERAL EXAMINATION: 

• temp: afebrile
• BP: 140/90 mmHg
• RR: 24cpm
• PR: 92bpm
• SPO2: 98% on RA

• Pallor: -
• icterus: -
• cyanosis: -
• clubbing: -
• lymphadenopathy: -
• edema: -

SYSTEMIC EXAMINATION:

CVS: S1, S2 heard

          no thrills

          no murmurs

RESPIRATORY SYSTEM:

           no Dyspnoea 

           no wheeze

           BAE +

          Trachea central position

          vesicular Breath sounds heard

ABDOMEN:

          Shape of abdomen: scaphoid

          no tenderness 

          no palpable mass

          No free fluid 

          no bruits 

          no organomegaly

          normal hernial orifices

          bowel sounds +

CNS: C/C/C to time, place, person

          No signs of meningeal irritation 

          no focal neural deficit found

          normal speech

          functions of cranial nerves, motor & sensory system are normal

Reflexes:  

       biceps triceps supinator knee ankle

right ++       ++          ++             ++         ++

left   ++        ++          ++             ++         ++

CEREBELLAR SIGNS:

Finger nose in coordination: NO

Knee- heel in coordination: NO

GAIT: normal

MUSCULOSKELETAL SYSTEM:     N

SKIN : N

EXAMINATION OF BREAST, ENT, TEETH & ORAL CAVITY, HEAD & NECK:

NORMAL

PROVISIONAL DIAGNOSIS:

?? CERVICAL SPONDYLOSIS

? LUMBAR SPONDYLOSIS

? SCIATICA

INVESTIGATIONS:

NO PALLOR

ECG

USG

ORTHO REFERRAL

Lateral view of neck

posterior view

Hemogram & CUE

LFT

RFT

TREATMENT:

1. Tab. TELMA-H PO/OD
2. Tab. Ultracet PO/BD
3. Tab. MVT PO/OD
4. Oint. DICLOGEL L/A BD
5. BP monitoring 6th hourly