55 yr old male

 Date of admission : 

A 55 year old male resident of Nalgonda presented to the causality with lower back ache and radiating pain to the left leg  since 3 weeks 

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic until 3 weeks ago after which he developed lower back ache which is sudden in onset, non progressive, aggravates on movement, relives on rest. 

History of trauma (slip and fall from stairs) 3 weeks ago 

The patient was taken to the local hospital where he was found to have L5 burst fracture on CT pelvis. 

No history of lifting heavy weights, fever, burning micturition, 

PAST HISTORY : 

k/c/o DM T2 since last 30 years 

K/c/o CAD since 2 years 

N/k/c/o of HTN, epilepsy, TB, asthma. 

History of  PCTA 2 years ago  

TREATMENT HISTORY: 

Tab. Metformin 500mg 

Tab . Roglibose 0.2mg 

Tab. glimidipine 2mg 

PERSONAL HISTORY : 

sleep : adequate 

Bowel and bladder : regular 

Appetite : normal 

Addictions: alcohol occasionally 

Allergies : none 

GENERAL EXAMINATION: 

Bilateral pitting oedema of upper and lower limbs . 

no signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, 

Vitals: 

Temperature: 98.2°

Pulse rate : 80

Respiratory rate : 18 cpm

BP: 110/80 mm/hg

Spo2: 98% / at RA liters

SYSTEMIC EXAMINATION : 

CVS: 

Thrills: no 

Cardiac sounds: s1,s2 + 

Cardiac murmurs : no 

RESPIRATORY SYSTEM: 

Dyspnoea: no 

Wheeze: no 

Position of trachea: central 

Breath sounds: vesicular 

ABDOMEN: 

Shape of abdomen : scaphoid 

Tenderness: not 

Palpable mass: no 

Hernial orifice:Normal 

Free fluid: no 

Bruits: no 

Liver: not palpable 

Spleen: not palpable 

Bowel sounds: yes 

CENTRAL NERVOUS SYSTEM: 

1. Level conscience: conscious 

2. Speech: normal 

INVESTIGATIONS: 

1. ABG: 

PROVISIONAL DIAGNOSIS: 

L5  unstable burst fracture associated with posterolateral corner injury (PLC).