WEEK 2 OPD CASES(MAY 1- MAY 7)
1.Op no. 20230502323
A 26Y/F
C/o Lower Back pain since 4 days, associated with B/L lower limb pain
C/ o frontal Headache since 1 day
No h/O fever, giddiness, nausea, vomiting, burning micturition.
Advised Admission, patient not willing for admission.
2.Op no- 20230503366
60Y/F
C/O neck pain since 1 month associated with headache and tingling sensation of both hands.
H/O lower back pain, dragging type, radiating to lower limbs and associated with tingling sensations.
Sent for Orthopaedics referral
3.Op no 20230503413
67/F
C/O lower back pain radiating along right lower limb associated with h/o tingling sensation since 1 week
No h/o trauma. N/k/c/o DM, HTN.
Advised admission for further evaluation but patient not prepared and not willing for admission
4.Op no. 20230502323
A 26Y/F
C/o Lower Back pain since 4 days, associated with B/L lower limb pain
C/ o frontal Headache since 1 day
No h/O fever, giddiness, nausea, vomiting, burning micturition.
Advised Admission, patient not willing for admission.
5. Op no. 20210511847
46y/F
C/O Neck pain since 3 months radiating to right side, associated with tingling sensation, lower backache radiating to right side
Weight gain of 5 kgs since 1 month, increased appetite, hair loss
ADVISED ADMISSION FOR FURTHER EVALUATION.
6. Op no- 20230503366
60Y/F
C/O neck pain since 1 month associated with headache and tingling sensation of both hands.
H/O lower back pain, dragging type, radiating to lower limbs and associated with tingling sensations.
7. Op no 20230503413
67/F
C/O lower back pain radiating along right lower limb associated with h/o tingling sensation since 1 week
No h/o trauma. N/k/c/o DM, HTN.
8. Op no. 20230504136
30/F
C/O fever for 6 months
C/O low back ache non radiating for 10 days
9. Op no. 20210213183
66/M
C/O pain in epigastric region for 1 day
C/O of lower back ache for 1 day
K/c/o bronchial asthma and on homeopathic medication.
10. Op no 20230500479
57/F
C/o back pain since 3 years
C/o leg pains since 3yrs
K/c/o CKD since 1 yr 3 HD done
K/c/o HTN since 5yrs on T.CLINIDIPINE 10MG
N/k/c/o DM, epilepsy,Tb
11. Op no:20230510267
40/F
C/o lower back pain since 10days(dragging type )
C/o tingling sensation of B/L lower limbs since 1 month
K/c/o type 2 DM since 6 months (on regular medication Glimi -m1)
Not a k/c/o HTN,TB ,asthma ,CVA.
12. Op no: 20230510307
38/F
C/o headache (frontal region)since 1 year
Associated with neck pain and radiating to both upper limbs
C/o facial puffiness since yesterday night
C/o low backache since 1 year
And Tingling and numbness of both lower limbs
Not a k/c/o HTN ,DM ,thyroid ,epilepsy ,CAD.
13. Op no:20230510341
33/M
C/o pain in lower back region since 1 week
C/o burning micturition since 1 week associated with increased frequency of micturition
No h/o Fever
Not a k/c/o HTN ,DM. ,TB ,epilepsy, CVA.
WEEK 3 OPD CASES(MAY 8- MAY14)
1. Op no:20230510341
33/M
C/o pain in lower back region since 1 week
C/o burning micturition since 1 week associated with increased frequency of micturition
No h/o Fever
Not a k/c/o Htn,DM,TB ,epilepsy,cva
Patient is advised for admission but not willing.
2. Op no:20210318049
C/o tightness of abdomen ,bloating + aggravated on intake of spicy food
C/o low backache since 2 years , aggravated on bending down ,relieved on rest
C/o nocturia since 2 months ,burning micturition+
No polyphagia and polydypsia
N/k/c/o HTN;DM;CVA;CAD,TB,Asthma
Patient is a known case of hypothyroidism since 5 yrs on medication since 1 yr 50 mcg ----->75 mcg po/od
K/c/o Renal calculi since 6 months ,used medications 2.
On examination:BP:130/90 mm hg
PR:84BPM
P/A:SOFT,NON TENDER
CVS:S1,S2 HEARD NO MURMURS
CNS:NFND.
RS:BAE PRESENT.NVBS HEARD.
PATIENT ADVISED FOR ADMISSION
BUT NOT WILLING
3. Op no. 20210522567
C/o b/l back pain from 1 month sharp type, intermittent in nature associated with aggrevated on physical exertion, deep seated pain
C/o hematuria 2 episodes in last 1 month
No h/o pedal edema facial puffiness
Pt advised for admission but not willing
4. Op no 20230512604
C/o headache with neck pain associated with left upper limb pain and tingling sensation since 15 days
Low backache since 1 week non radiating
No C/o photophobia phonophobia vomiting lacrimation
N/k/c/o DM HTN TB asthma.
5. op no:20230518608
33/F
C/o low back ache since 20 days
Left sided radiating to left lower limb
Tingling sensation present
No C/o numbness,weakness
N/k/c/o HTN,DM,Asthma,TB,epilepsy,thyroid disorders
No similar complaints in the past
No pain/tingling of right lower limb
O/E:
Pt is c/c/c
RS:BAE+
NVBS
CVS:s1,s2+
No murmurs
CNS:NFND
Patient advised for admission but not willing
6. op no:20230519836
55/M who is a daily labour by occupation wakes up every morning at 7am,then at 8 am he has breakfast ,then he goes to daily labour work but stopped his daily labour work due to sudden onset weakness left upper limb and left lowerlimb 3years back ( CVA) and was on ecospirin av but he stopped medication after using for 15days . He was not using medication due to affordability issues .
H/o low backache radiating to b/l lower limbs associated with tingling sensation of distal extermities 1yr
And he was given nsaids with pregabalin.
He noticed development of pedal edema after using pain killers he stopped taking them
Now ,came with Complaints ofdragging type of pain lf lowerlimb so he was unable to do his daily labourer job
K/c/o HTN since 3years but not using any medication
0/E
Patient c/c/c
CVS: s1s2 heard
RS: BAE + NVBS +
P/A soft ,Non tender
CNS: antalgic gait
Advised admission but not willing for admission
7. O.P: 20230519436
50/F
Daily Labourer by occupation came with C/O: Lower back ache and tingling sensation in both the feet since 2 months,She stopped going to work since then and complains of pain even while rest
K/c/o: HTN since 1 yr. and on regular medication.
O/E:
Pt is C/c/c
No tenderness in neck
No tenderness in spine
No restriction of movements
CVS : S1 S2 + No murmurs
RS : BAE + NVBS +
P /A: Soft NonTender
CNS : NFND
Diag : ? Lumbar spondylosis.
8. Op no 20210411219
32 M
A supermarket worker came with c/o pain in lower rgt sacral dimples radiating to rt lumbar region since 15days
No h/o increased frequency of urine, burning micturation,fever
Pain is increased on bending forward and relieved on its own without taking medication
Routine
Regular travel on bike from home to shop
Mild pain experience on traveling after bending forward which is dragging type of pain experience atleast 4times per day
Not a k/c/o DM,htn,tb,cva,cad, epilepsy, asthma
Diagnosis -?lower backache
Pt was advised for admission but not willing
9. Op no 20230521293
60F
Pt was homemaker do farming activities during free time but stopped working from past 20yrs due to increase in age from that she wakes around7am and do normal small household activities and takes rest but from past 2month she has difficultly in standing, walking,passing urine
Pt came with c/o pain in low back, dragging type of pain radiating to left lower limb upto knee since 2-3 months
Able squat and stand byherselfand pain on standing
K/c/o htn since 10yrs on medication (atenolol 50mg+amlodipine 6mg) po od
Pt is c/c/c
Musculoskeletal system examination
On right side
Straight leg test -60degree positive
Pain on abduction,adduction, external rotation of hip joint
Sacroiliac joint tenderness
Cvs s1s2 heard no murmur
Cns nfnd
Rs BAE present
P/a soft non tender
Diagnosis -?sciatica
Patient was adviced xray of spine and adviced for admission but not willing
10. Op no 20210114449
32F
Teacher by occupation
Her daily routine
Wakes up at 530am in the morning and completes her household chores by 7am and have her breakfast by 8 am and goes to school at 1230pm she will have her lunch and continues the work comes back home by 5pm and do the house work and eats dinner by 8pm and goes back to sleep by 10pm
came with complaints of low backache since 1 month non radiating not associated with tingling sensation of lower limb
No h/o trauma
H/o increase in pain on prolonged sitting or bending forwards decreased on lying down on bed
No h/o renal calculi
O/E
SLRT -Ve
Paraspinal muscle tenderness
Cvs S1 S2+
RS BAE+
P/A soft and non tender
Provisional diagnosis:Myofacial pain due to overuse
WEEK 4 OPD CASES(MAY 15 -MAY 21)
1. Op no.20230523500
C/o of neck pain since 4 days
Radiating towards right upper limb associated with tingling sensation,no history of weakness ,no history of trauma.
History of headache on and off since 10 years.
No history of unilateral headache.
Headache is associated with nausea and vomitings.
Photophobia present and phonophobia present.
Cheif complaints of lowerbackache radiating to right lower limb.associated with tingling since 2 days.
No history of tingling or numbness over the trunk or face.
General examination:Patient is conscious coherent and cooperative.
Moderately built and moderately nourished.
No palloricterus,cyanosis,clubbing,lymphadenopathy,edema.
Vitals:
Bp:110/80 mmhg
Pr:80 bpm
Rr:18cpm
Temp :afebrile.
Systemic examination:
Cvs:s1,s2 heard No murmurs
Rs:BAE+and no murmurs.
PA:SOFT AND non tender
CNS:
Power:ul : 5/5.
Ll: 5/5.
TONE:NORMAL
Reflexes:B:1+
T:1+
S:1+
K:1+
A:--
Treatment ×1week
Tab: Ultracet BD
1/2--0---1/2
Tab:multivitamin OD
0--1--0.
2.Op no 20230525827
44/M
C/O low Back ache since 1 Year
Pricking type of pain in both feet since 6 months
B/L knee Pains Since 5 months
H/O pain in left loin radiating to the front of abdomen for which he visited hospital and was found to have renal calculus and has started medication for the same since then but pain did not subside.
Daily Routine - wakes up at 6 am & he climbs tree for toddy.
N/K/C/O HTN, DM, TB, Asthma,CAD,CVA, Epilepsy, Thyroid Disease
Vitals:
Bp:80/60 mmhg
Pr:86bpm
RR- 18 cpm
P/a: soft,non tender
Cvs:S1S2 heard ,no murmers
CNS: NFND
R/S- BAE,NVBS heard
L/E- no spine deformity/ tenderness
Crepitus + in both knee joints
3.Op no:20230527237
50/F c/o neck pain since 2 yrs
C/o difficulty in walking with lBA ,non radiating since 2 years ,increased on bending, unable to extend the limb completely(more since 6 months)
C/o neck pain right more than left,radiating to shoulder with mild restriction of movements to right
Used NSAIDS on and off
O/E:-
SLR-negative
Right Hip:- restriction with pain of felxion,extension,adduction,abduction
Tenderness along joint line
Left Hip:- mild tenderness with restriction
Reflexes(2+)
Neck: paraspinal tenderness with restriction of right sd neck
Gait:- Antalgic with right waddle
N/k/o HTN, DM,epilepsy,asthma thyroid,CVA
Vitals:
Bp:100/80mmhg
Pr:82bpm
P/a: soft,non tender
Cvs:S1S2 heard ,no murmers
CNS: NFND
R.s:BAE,NVBS heard
4. Op:20230526412
20/F c/o lower backache,dragging type radiating to the cervical spine region with headache in occipital region since 1 week
No fever,vomoting.
C/o giddiness since 7 to 8 yrs only when temperature present
H/o angioplasty done 18 yrs back not on any medication
N/k/o HTN, DM,epilepsy,asthma thyroid,TB.
Vitals:
Bp:90/60mmhg
Pr:80bpm
P/a: soft,non tender
Cvs:S1S2 heard ,no murmers
CNS: NFND
R.s:BAE,NVBS heard
5. Op no. 20230426632
46/M
C/O tingling, numbness in right hand little finger since 10 days
C/O low backache since 10 days (stiffness present) ,no h/o trauma, aggravating factors-on bending forward pain increases, relieving factors-pain decreases on walking for some distance
K/C/O HTN since 3 months on medication (metoprolol 25 mg and clinidipine 10mg)
Vitals:-
BP:-130/80 mm hg
PR:-86bpm
6. OP NO:20230529824
C/o
-lower backache since 2 months which is increased on bending downwards
-neck pain since 2 months and no restriction of movements
Vitals:
BP:120/80mmHG
Weight:109kg
CNS: NFND
CVS: S1 and S2 heard, no murmurs
RS: BAE,NVBS heard
P/A: soft and non tender
Not a known case of DM,HTN,asthma,epilepsy,TB and thyroid abnormalities
Advice:
-Diet modification
-Avoid junk food
-Regular exercise
7. Op no:20230531635
76/M
C/o lower back ache since 2 years
Both knee pain since 2 yrs
Neckpain since 2 yrs
Headache since 2 yrs
K/c/o HTN since 2 yrs and on regular medication
N/k/c/o DM,TB, epilepsy and asthma
O/E
Tenderness present in cervical and lumbar spine
Extension of neck is limited
Crepitus present in knee joint
Daily routine -
Wakes at 6am eats breakfast at 8am and lunch at 1pm(rice and curry) and dinner at 8pm(Roti).
Used to do farming before 2 yrs but stopped working due to backpain.
CVS- S1 S2 heard no murmurs
RS-BAE+ NVBS
P/A- soft non tender
CNS-NFND
WEEK 5 OPD CASES(MAY 22- MAY 28)
1. OP NO: 20230535214
60F
C/o low backache since 5 to days radiating to left lower limb
Neck pain since 1 week with head ache associated with giddiness / tingling sensation of upperlimbs bilateral
k/c/o HTN since 3 years ,
n/k/c/o thyroid,epilepsy,cad,cva
H/o trauma to head due to slip and fall
IC bleed left hemiplegia since 2years
H/o lumbar and cervical spondylosis 1 year back
O/E:
Cvs- s1s2 heard
RS - BAE + , NVBS heard
P/A - soft,nt
CNS HMF intact
Pupils b/l nsrl
Cranial nerves intact
Motor system normal
Tone normal
Power ul. Ll
Rt 4/5 4/5
Lt 3/5 2/5
Reflexes
B T S K A Plantar
Rt. - - - - - flxn
Lt +3 +3 +3 +3 +2. Extsn
Advice
Physiotherapy of left upper and lower limb
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