47F with lower back pain

NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT. 

PATIENT HISTORY: Pt is 47 yr old, homemaker.

16-17 yrs ago, went to Physician w/c/o intense pain in rt. upp. quadrant of the abdomen spreading to the chest and back. Dr. diagnosed it to be due to some issue with the gallbladder. Cholecystectomy was done 15 days later. The pain resolved after that.

8-9 yrs ago, c/o constipation, bleeding pr (2-3 times the small amount). Burning sensation after passing very hard stool. 10-12 days later went to Dr. who performed a small? Sx after which the bleeding stopped. Was given laxatives for constipation.

For the past 1-1.5 yrs, c/o diffused abd pain, bloating, tenesmus

1 yr ago, while sitting down and weeding the lawn suddenly felt intense pain in lower abdomen. She quickly stood up and felt the urge to urinate but urine won't come out. She claims it can be due to emotional stress since her son left the house to build his own house far away.

The next day, she woke up at 8 am but started c/o left side lower back pain which spread to the whole of her left leg. The pain was unbearable and a few days later taken to a local healthcare center. They failed to arrive at any conclusion and she got discharged. Because of the pain, she was almost bedridden and couldn't move around. No such relieving factors but exaggerated while performing chores and movements. Was taken to another Dr. who diagnosed it to be due to nerve root compression. Suggested Sx, prescribed medicines and exercises after which her pain reduced significantly. But she did not do the Sx. 

Till 3-4 months ago, her leg pain was somewhat ok with medications and exercises. But, she started c/o whole body itchiness without rashes, described as felt as small bumps under the skin like allergic reactions. Went to a local pharmacy and took allergy medications for 2 days which caused some relief. Self-diagnosed it to be side effect of those pain medications and stopped medications on her own accord for 1 wk. Again started c/o severe pain in the left lower back and left leg with paresthesis. Went to Dr. who did MRI and Sx was recommended again. 

For the past 1 month, c/o muscle cramps frequent at night in the cuff muscle of rt leg only.

Pt denied H/o DM. 

Claims her BP remains at the lower side (sometimes feels lightheaded, and malaise), but feels better on drinking milk and taking vit. tab.

Addiction- Consuming Paan since age childhood, 45-50/day. 

Menstrual History: 12 yrs ago, menstrual cycles stopped suddenly. Went to Dr. who said not to worry. But for the next 2 months also no menstruation so USG was done and uterine? fibroids detected. Menstruation had stopped since then. No treatment sought for uterine? fibroids.

CHIEF COMPLAINT AND Pt. REQ.:

Left lower back and leg pain for the past 1 yr aggravated for the past few months.

Pt wants consultation about whether to perform PIVD Sx.

FAMILY HISTORY: 

Mother - c/o SOB

Elder sister - lower back pain

Sister - gastric problems (acidity, indigestion)

PROVISIONAL DIAGNOSIS:  L4-L5 PIVD


 






REPORTS:














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