A CASE OF LOWER BACK PAIN IN A 38 YEAR OLD

This is an online e log book 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 series of inputs from available global online community of experts with an aim to solve those patient’s clinical problems with collective current best evidence based inputs. This e-log book reflects my patient centered online portfolio and your valuable inputs on the comments is welcome.”

A 38 year old female resident of nakrekal who is a daily wage labourer came to the OPD with complaint of
CHIEF COMPLAINTS
Lower back pain since 6 months
Headache since 20 days
Shortness of breath Grade 2


 HISTORY OF PRESENTING ILLNESS
PATIENT WAS APPARENTLY ASYMPTOMATIC 6 MONTHS AGO WHEN SHE HAD
Lower back pain on both sides draging type radiating towards the coccyx 


PAST HISTORY
K/C/O DIABETES 
Not a known case of
Hypertension
Tb
Asthama
Epilepsy
Cvd
Chemotherapy

FAMILY HISTORY
Not significant

PERSONAL HISTORY
Diet - mixed
Appetite - 
Bowel and bladder - adequate
Allergies -no
Addiction -none

SURGICAL HISTORY
she had a tympanic membrane perforation due to which 
GENERAL EXAMINATION
Patient is conscious,coherent and cooperative and oriented to time, place and person

Height
Weight
BMI
Thin built and moderately nourished

Vitals
Temperature
Pulse
BP
RR

Pallor
Icterus
Clubbing
Cyanosis
Lymphadenopathy
Pedal edema

SYSTEMIC EXAMINATION
CVS
RESPIRATORY SYSTEM
ABDOMEN
CNS

INVESTIGATION

PROVISIONAL DIAGNOSIS

TREATMENT

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