Case of a 24 years old woman with back pain .

September 19, 2022

Case of a 24 years old woman with back pain .

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardians' signed informed consent. This Elog reflects my patient-centred online learning portfolio.

This is the case of a 24 years old female, who is a housewife and a resident of Kolkata, West Bengal.

CHIEF COMPLAINT

The patient has the chief complaint of

lower back pain from 4 months
neck pain from 10 days.

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 16 months ago (June 2021), the patient suffered a miscarriage at the gestational age of 6-7 weeks. 6 months later in December 2021 the patient went to a doctor for a check up and was tested for TORCH infections in which antibodies for Rubella and Cytomegalovirus were detected. The patient was prescribed Spiramycin , that she took for 21 days.

15 days after finishing the course (Feb) , she started experiencing abdominal cramps in the lower abdomen. It was not associated with nausea and vomiting. The cramps were so severe that she would have to lie down on the bed and was not able to do a lot of work. The patient went to a doctor in April 2022. An ultrasound was done and the patient was diagnosed with polycystic ovarian disease. The patient was prescribed medication (Cyproterone acetate + Ethinylestradiol tablets) that she took for three months. The severity of the pain reduced but is still present.

By the end of June, two months later, she started experiencing lower back pain predominantly on the left side. The pain was gradual in onset. Initially, the pain was less, hence she did not notice it. The pain gradually progressed. Over the past 3 months, the pain has increased. It is continuous in nature, a burning type of pain associated with a local rise in temperature. It aggravated on bending forwards even for a minute, doing strenuous work or climbing stairs, cooking, standing or sitting for a long time. The pain was relieved by taking medication and massaging the area. The pain would radiate to the left leg till the feet and for the past 1 month the left arm also. Occasionally right arm is also involved. It is not associated with any change in the gait.

The patient also complains of neck pain from 10 days. Associated with weakness of the neck and the feeling of the neck being pulled to the back. The pain is similar in character to the pain present in the lower back. It is a burning type of pain, that is radiating to the lower part of the head.

The patient also complains of breathing problems aggravated by stress or in crowded areas.

The patient also complains of nausea after eating food from 2 weeks.

PAST HISTORY

Not a known case of DM, hypertension, asthma, TB, Thyroid condition, CVD, or Epilepsy

FAMILY HISTORY

Father - Known case of DM

Grandmother- Has joint pains.

PERSONAL HISTORY

The patient is prone to stress

DIET- Mixed diet

APPETITE- Normal

SLEEP- Disturbed sleep since some days ( patient couldn’t recall since when)