This is an online E log book to discuss our patients deidentified health data shared after taking his/her/guardians signed informed consent.

Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.

This E log book also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

CASE PRESENTATION:

A 36 year old male who is farmer by occupation and resident of Koch behar , West Bengal came with chief complaints of lower back ache with pain radiating to right lower limb since 20 days.

Patient was apparently symptomatic 20 days back then he developed sudden pain in the lower back with pain radiating to right lower limb, associated with calf pain.

H/o massage done 20 days back ( in view of pain in the right lower limb which was aggravated  after that) , then he went to a near by RMP for medication (pain was relived by that medication ) . Pain was aggravated on on walking and relieved be rest.

History of surgery in March 2020

                Surgery- L5-S1 right fenestration and discectomy under general Anesthesia.

Not a known case of DM , HTN , TB , Epilepsy.

Not on any medication.

Personal history:

Appetite normal

Diet mixed

Bowel and bladder regular

Sleep adequate 

Chews tobacco.

General examination:

Patient is conscious coherent and cooperative.

No pallor icterus cyanosis clubbing lymphadenopathy edema.

Gait

Vitals

Temperature 98.6F

Bp : 120/80mmHg

PR: 84bpm

RR: 16cpm

GRBS: 112


Systemic examination:

CVS : S1 S2 heard , no murmurs

RS : BAE +

P/A : soft non tender

Leg raise test 

Right 60 degrees

Left 90 degrees

CNS : 

Higher mental functions normal

Speech normal

Memory intact


Motor examination

Power.         R.              L

UL.            P 5/5            5/5

                  D 5/5          5/5

LL.              P 4/5         5/5

                    D 4/5         5/5

Tone UL normal

          LL normal

Reflexes B  T  S   A  K   P 

            R 2+ 2+  2+   3+ 3+  Withdrawal

            L 2+ 2+ 2+  2+    2+  Extension






Investigations:


















Patient referred to Dermatology I/v/o Dry raised patchy lesions covered with silvery scales on both knees and right arm
On Examination multiple well defined polisized scaly plaques (hypopigmented) noted over both buttocks , right arm and right knee region since 4 months
Diagnosis: Tinea corporis et Cruris + seborrheic capitis
Treatment: 
SALISIA KT Shampoo alternate day for two weeks
ZODERM-E cream L/A Bd for 2 weeks
T.ATARAX 10mg OD for 2 weeks
CAP . ITRACONAZOLE 100mg BD for 2weeks









Orthopaedics Opinion:
?L4 L5 spondylolisthesis
Treatment:

Cap .TRIGABANTIN 300mg Hs
Tab . HIFENAC MR PO BD
Tab. NEUROKIND PO OD
Tab . PAN 40 mg PO OD
Active / passive ankle movements (physiotherapy)



Diagnosis : L3 L4 Never compression with L4-L5 sensory nerve involvement
Treatment:
Tab . PCM PO/QID
Cap .TRIGABANTIN 300mg Hs
Tab . HIFENAC MR PO BD
Tab. NEUROKIND PO OD
Tab . PAN 40 mg PO OD













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