4O/F CAME WITH THE C/O PAIN IN UPPER AND LOWER BACK SINCE 2 YEARS
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XRAY AP VIEW ON RT BENDING
XRAY AP VIEW STANDING POSITION
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A 40 YEAR OLD FEMALE WHO IS RESIDENT OF WEST BENGAL CAME WITH
CHIEF COMPLAINTS OF:
Pain in upper and lower back since 2 years.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently alright 2 years ago then she had pain in upper and lower back which is insidious in onset and gradually progressive to current condition, pain was radiating to the sides and the neck, relieving on taking medication and physiotherapy.
Pt had history of travelling on bike upto approx 48kms for 10 yr and she is working as a teacher,
Since 2 yrs she had increased pain in the back and now she is going to school by car. Past 1 yr there is severe pain in back even after doing physiotherapy and her husband also noticed some abnormality in shoulder position (unequal shoulder position)and back(structural) and went to local hospital and they advised x -ray whole spine in which they diagnosed scoliosis and they said it may require surgical correction . After that now they approached our hospital.
she also complains of pain in the right shoulder while writing with chalk on board and stops writing and continues in a while. Patient also gives h/o pain during work on bending forward and relieving on standing straight or lying on flat surface. Patient is unable to sit straight for a long time and leans back for support.
Patient is unable to sleep in supine position and preferred to sleep on one side.
No h/o tingling or numbness in the back and lower limbs.
Pt also c/o easy fatiguability and shortness of breath (grade II) since 10 yrs.
No h/o fever, cold , cough, headache ,chest pain,, palpitations, pain abdomen, burning micturition, increased urination , constipation, loose stools.
PAST HISTORY :
H/o pain in the upper and lower back since 10yrs
No h/o hypertension, DM, asthma, TB, epilepsy , CAD, CVA, thyroid disorders.
PERSONAL HISTORY:
Diet: Mixed
Appetite: Normal
Sleep: Normal
Bowel and bladder movements: Regular
No addictions.
Daily routine:
She wakes up in the morning around 6.30 am and gets fresh up and do excercise for 1/2 hr .
7- 9 am : She prepares breakfast and get her son ready for school.
By 10.30 am she goes to school as she is a teacher by profession and will take classes for students.
1 - 2 pm she will have her lunch and again she takes classes upto 4 pm
By 5 pm she reaches home and will do household chores and prepares dinner and will have dinner at around 8pm and goes to bed by 11 pm.
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative and well oriented to time, place and person.
Moderately built and nourished.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema.
VITALS:
Temp:98.4F
PR: 92 bpm
BP: 110/70mm hg
RR:19cpm
SPO2: 97%
Systemic examination:
CVS: s1, s2 heard ,no murmurs.
R/S:
Upper respiratory tract - normal
Lower respiratory tract-
Inspection:
Chest bilaterally symmetrical,
Shape- elliptical
Trachea- Central
Palpation:
Trachea is Central
Normal chest movements
Vocal fremitus is normal in all areas
Percussion: in sitting postion
Rt. Lt
Supraclavicular. N(resonant). N
Infraclavicular. N N
Mammary region. N. N
Inframammary region. N. N
Axillary region. N. N
Infra axillary region. N. N
Supra scapular region. N. N
Interscapular region. N. N.
Infrascapular region. N. N
Auscultation:
Normal vesicular breath sounds
No added sounds
Vocal resonance is normal in all areas.
P/A : Soft, non tender, no organomegaly
CNS:
Higher motor functions - intact
Cranial nerves - intact
Motor system:
Rt- UL. LL. Lt- UL. LL
Bulk - N N. N. N
Tone - N. N. N. N
Power - 5/5. 5/5. 5/5. 5/5
Reflexes:
UL LL
Biceps. 2+. 2+
Triceps. 2+. 2+
Supinator. 2+. 2+
Knee. 2+. 2+
Ankle. 2+. 2+
Sensory system: intact
Co ordination is present
Orthopedic referral I/V/O lower back and upper back pain on 31/12/23
XRAYS ON 2/1/24
Xray left bending
XRAY LATERAL STANDING POSITION
Orthopaedic referral I/V/O review with reports on 4/1/24
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