A 65 years old with Burning sensation over left UL and LL since 2 years

9/12/2023

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Sanidha Singh 

Roll no.- 98

Unit 4

 CHIEF COMPLAINT: 

 Burning sensation over left UL and LL since 2 years 

HISTORY OF PRESENTING ILLNESS: 

Patient wan apparently asymptomatic 2 years ago then developed burning sensation of left UL & LL  associated with tingling & numbness which is  intermittent, aggravated on lying on the bed- left side & not relieved with medication.

Not associated with weakness of UL & LL

Not  associated loss of sensation.

H/o left knee joint pain since 2 years not relieved  with medication.

No H/O - Fever, chest pain, palpitation , orthopnea , PND.

H/O bloating and burning type of pain in epigastrium.

H/O SOB grade II MMRC

No H/O burning micturition, decreased urine output

PAST HISTORY:

K/C/O HTN since 5 years on unknown medication

N/K/C/O DM, epilepsy, CVA, CAD, thyroid disorder.

PERSONAL HISTORY:

Diet:Mixed 

Appetite: decreased

Sleep: adequate

Bowel,bladder:regular movements.

Addictions: Occasional alcoholic - weekly once (90ml) since 40 years.

Tobacco smoking sutta 3 per day since 50 years.

GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent,cooperative,well oriented to time,place,person. He  is moderately built and nourished.

No signs of pallor, icterus, cyanosis, clubbing, lymphoedenopthy, oedema. 

Vitals:

PR- 86 bpm

RR- 16 cpm

BP-140/90mm hg

GRBS- 90 mg/dl

Temp- 98 F

SYSTEMIC EXAMINATION: 

Per Abdomen :  Bowel sounds present, Normal shape, No tenderness, No palpable masses

CVS : S1 & S2 Heard , No murmurs 

RS : Central position of trachea, Vesicular breath sounds, No wheeze, no dyspnea

CNS : NAD

INVESTIGATIONS:

TREATMENT:

Tab PREGABALIN 75 mg HS

Tab  PAN 40 mg OD

Syp SUCRALFATE 15ml BD

Tab AMLODIPINE 5 mg OD

BP monitoring 4th hourly

Orthopedic referral was done on 9/12/23:

Neck pain: mild to moderate, diffuse, no radiation, increased on neck movements.

Back ache: mild to moderate LS region, radiating to lower limb to toes.

Local Examination: Sensory impairment over L5- S1, no motor deficit. 

Diagnosis: ? Cervical spondylosis with lumbar spondylosis with L5- S1 root compression.

X- Ray C spine AP and Lateral —- Normal. 

X-Ray LS Spine AP —- Osteophytes @ L4- L5 + Osteoporosis. 

Review with L S Spine lateral view