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Ashithamma
Ashithamma
Patient apparently alright 1 years back, when she started having low back pain from 1 years, insidious onset, gradually
progressive, more on standing for long duration, aggravated from 6 months.
h/o pain , pins and needle type, radiating to Right lower limb, insidious onset, gradually progressive, mildly relieved on
medications, no h/o diurnal variation,
h/o difficulty in walking present, h/o difficulty in getting up from squatting position,
Past History
Personal History
diet-mixed
appetite-normal,
sleep- disturbed
Family history:
Not significant
GENERAL EXAMINATION:-
T- normal
BP- 120/80 mm HG
RR- 16/min
Pulse- 84/min
GCS- E4V5M6
CN 1:Intact
CN 2:
Fundus: Normal
CN 5- V1 V2 V3 Normal
Sensory: Normal
Motor : Normal
Corneal reflex-
CN 7- Normal
CN 8-
CN 9,10:
Uvula – Midline
Palatal movement- Normal
CN11: Normal
CN12
:
Tongue - Bulk - Normal
Deviation - No
POWER:-
LEFT RIGHT
Reflexes :
Superficial- present
Abdominal reflexes- present
Plantars- flexor
Deep Tendon Reflexes : B T S K A
Right 2+ 2+ 2+ 2+ 1+
-
Left- 2+ 2+ 2+ 2+ 2+
Sensory system:-
Touch – intact
Rhomberg’s sign- negative
2 point discrimination test- intact
Vibration sense- intact
Joint position sense-
Cerebellar signs:-
Dysdiadochokinesia- absent
Finger-nose test- intact
Finger-nose-finger test- intact
Knee-heel-shin test- intact
Pendular knee jerk- absent
Rebound phenomenon- absent
MRI
neurosurgery):-
Advice:- L4 L5 TLIF