General Medicine

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A 40 years old male patient came to OPD as a chief complaint of pain over lower back since 1½year gradual onset of pain on right lower limb aggravated on bending,prolonged working,reduced on rest.                 

HISTORY OF PRESENT ILLNESS:-

A 40 years old male patient who is daily labour and farmer by occupation,has pain over lower back since 1½year has gradual onset of pain on right lower limb aggravated on bending ,prolonged working,reduced on rest(Identified as L3-L4,L4-L5 lumbar canal stenosis) surgery done on Monday,surgery proposed L3-L4 laminectomy,posterior lumbar interbody fusion done at L4-L5 level,posterolateral fusion done at L3-L4 level and has dragging type of pain.

PAST ILLNESS:-

No trauma

No fever/loss of weight/loss of appetite

Not a k/c/o DM,HTN

K/c/o TB 4 yrs back &used ATT for 6 months.

PERSON HISTORY:-

Diet:Mixed

Appetite:Normal

Sleep:Adequate

Bowel Movements:Regular

Bladder Movements:Normal

GENERAL EXAMINATION:-

Patient is conscious,coherent, coperative

No history of cyanosis,clubbing,

lymphadenopathy,pallor,pedal edema

Physical states:Moderately built

Hydration:Adequate

VITALS:-

Temp:Afebrile

Bp:140/90mm/Hg

PR:82bpm

RR:7cpm

SYSTEMIC EXAMINATION:-

Lungs:BAE+,Crepts+ not in L lower lobe of lung

CVS: S1,S2+

PA:Soft,Non tender

CNS:NAD

Pre-operative diagnosis:-L3-L4,L4-L5 central canal stenosis.

INVESTIGATION:

TREATMENT:-