Medical Case Sheet

Patient Name: Z

Age: 35 years

Gender: Male

Date of Admission:

Date of Examination: 

Chief Complaint:

Pain in the low back region for 1 year, aggravated for the past 1 month.

Pain radiating to the left leg for 1 month.

Hospitalized for 1 week.

History of Present Illness:

The patient developed dull aching pain in the lower back 1 year ago after a fall while riding a bike.

Initially, the pain was mild and intermittent, but it has progressively worsened over the last month.

The pain radiates from the lower back to the left leg, suggestive of sciatic nerve compression.

The patient finds the pain worsens with physical activity, especially during bending, walking, and lifting.

No bowel or bladder disturbances reported.

The patient has not experienced any tingling, numbness, or weakness in the legs. 

Past Medical History:

No history of hypertension (HTN).

No history of diabetes mellitus (DM).

Smoker for the past 10 years (10 cigarettes/day).

No significant surgical history.

Family History:

No family history of spinal disorders or neurological conditions.

Personal and Social History:

The patient is a smoker but does not consume alcohol.

Works as a mechanic, requiring physical labor.

General Examination:

Vitals:

Temperature: 98.6°F

Pulse: 78 beats/min, regular

Blood Pressure: 120/80 mmHg

Respiratory Rate: 18 breaths/min

General Condition: Well-nourished, moderately built

Pallor: Absent

Icterus: Absent

Cyanosis: Absent

Clubbing: Absent

Lymphadenopathy: Absent

Edema: Absent

Systemic Examination:

Spine Examination:

Inspection: No obvious deformities or abnormal curvatures.

Palpation:

Tenderness over the L4-L5 region.

Muscle spasm in the lumbar area.

Range of Motion:

Restricted in forward flexion, lateral bending, and extension due to pain.

Special Tests:

Straight Leg Raise (SLR): Positive on the left side at 40 degrees.

Slump Test: Positive, indicating nerve tension.

Neurological Examination:

Motor Function:

Power: Normal (5/5) in both legs.

Sensation: Reduced sensation along the L5 dermatome in the left leg.

Reflexes:

Knee jerk: Normal bilaterally.

Ankle jerk: Diminished on the left side.

Investigations:

Laboratory Investigations:

Complete Blood Count (CBC): Within normal limits.

Erythrocyte Sedimentation Rate (ESR): Slightly elevated, suggestive of mild inflammation.

Imaging Studies:

X-ray of Lumbar Spine:

Loss of disc height at L4 - L5 level.

No evidence of fractures.

MRI Lumbar Spine:

Disc herniation at L4-L5 with compression of the left nerve root.

Mild degenerative changes noted.

Nerve Conduction Studies (NCS):

Showed decreased conduction velocity in the left sciatic nerve, consistent with nerve root compression.

Differential Diagnosis:

1. Lumbar Disc Herniation (L4-L5):

Based on radiating pain, positive SLR test, and MRI findings of disc herniation.

2. Lumbar Spondylosis:

Degenerative changes noted on MRI, may contribute to chronic back pain.

3. Piriformis Syndrome:

Less likely as pain is exacerbated by spinal movements rather than hip rotation.

4. Spinal Stenosis:

Unlikely due to the absence of bilateral symptoms or neurogenic claudication.

Provisional Diagnosis:

L4-L5 Disc Herniation with Left-Sided Sciatica.

Final Diagnosis:

L4-L5 Disc Herniation with Left Radiculopathy.

Management Plan:

Medical Management: 

Name of medicine:

Dose:

Non-Pharmacological:

1. Physical Therapy:

Core strengthening and lumbar stabilization exercises.

Heat therapy for muscle relaxation.

2. Lifestyle Modifications:

Smoking cessation to promote healing and reduce inflammation.

Weight management to reduce strain on the spine.

Surgical Options (if no improvement in 6-8 weeks):

Microdiscectomy or Discectomy for decompression of the nerve root.

Advice:

1. Rest: Avoid activities that strain the back, such as heavy lifting or prolonged standing.

2. Posture: Maintain good posture while sitting and standing.

3. Follow-up: Reassess after 2 weeks to evaluate pain and mobility.