CASE
PRESENTATION
Area- NEURO SURGERY WARD
Anupriya Arya
1820087
BPT 7th semester
Batch 2020
SUBJECTIVE ASSESSMENT
DEMOGRAPHIC DETAILS
- Name : Urmila
- Age: 38yr
- Gender: female
- Occupation: House-wife
- Address: Saharanpur
- Hand Dominance: Right
- D.O.A : 26 sept ,2024
CHIEF COMPLAINT:
- Patient complains of pain in lower back and radiating into both lower
limb from posterior gluteus to calf region, since 1 year Rt >Lt. Difficulty
to perform household activities.
HISTORY OF PRESENT ILLNESS:
The patient was in her usual state of health for the past year until she
began experiencing pain in the center of her lower back (lumbosacral
region). Despite taking medication from a local healthcare provider, she
did not find relief. While performing a household activity
(cleaning/dusting), she slipped and fell onto her buttocks, hitting her
lower back against the edge of a tile. Following this incident, her pain
progressively worsened each day and started radiating into the right
gluteal region, then to the posterior aspect of the thigh and calf.
Eventually, similar symptoms developed in her left leg. Due to the intense
pain in her right leg, she has been bending her trunk to the left or sitting in
a crook lying or butterfly position for relief. She sought treatment at a
nearby healthcare center in Saharanpur, where she was given analgesics
but did not experience significant relief. Consequently, she visited the
orthopedic outpatient department at MM Hospital, where the orthopedist
referred her to a neurology specialist for further evaluation and treatment.
Pain history :
• SITE OF PAIN: L4-L5 & L5-S1 Region
• TYPE: Intermittent pain
• ONSET: Night
• NATURE: Radiating pain
• AGGRAVATING FACTOR: While doing house hold activity, walking,
forward bending
• RELIEVING FACTOR: Resting, Supine lying, Left side bending and in
crook position
- Past history: Patient had a history of fall on buttocks, past 1
year
- Past surgical history: C- section
- Past medical history: No
-Socio-economic history:
lower middle class
• SEVERITY: NPRS: 6/10
• BODY CHART:
ON OBSERVATION:
• Supine lying
• Head elevation
• Right shoulder protracted & Elbow flexed
• Wrist flexion , ulnar deviation and finger flexion
• Right hip lifted upward and left downward
• Lower limb extended and ankle ext. rotation
• Foot eversion
• Cannula placed over dorsal aspect of the left hand
• folley’s Catheter
• Chest expansion normal
• Side bending towards left side
• No swelling and edema in extremity
ON EXAMINATION:
On Palpation:
• Grade 2 tenderness(lumbosacral region)
• Region over L4-L5 and L5-S1
• Swelling absent(Lumbar region)
• Muscle tone normal
• Atrophy of the calf muscles in right limb
• Left side bending
ONE SIDE BENDING
MMT OF UPPER LIMB:
MOVEMENT RIGHT LIMB LEFT LIMB
Shoulder flexion 5/5 5/5
Shoulder extension 5/5 5/5
Elbow flexion 5/5 5/5
Elbow extension 5/5 5/5
Wrist flexion 5/5 5/5
Wrist extension 5/5 5/5
MMT OF LOWER LIMB:
MOVEMENT RIGHT LIMB LEFT LIMB
Hip flexion 3+/5 4/5
Hip extension 3+/5 4/5
Knee flexion 3+/5 4/5
Knee extension 3+/5 4/5
Ankle dorsiflexion 4/5 4/5
Ankle planter flexion 4/5 4/5
SENSORY EXAMINATION:
- All sensation is intact in all limbs ( superficial
sensation , deep sensation & cortical sensation )
- only Numbness is their in lower limb
DEEP TENDON REFLEX:
REFLEX GRADE IN Rt. LIMB GRADE IN Lt. LIMB
KNEE REFLEX +2 +2
ACHILLES TENDON REFLEX Not elicit Not elicit
AUSCULTATION:
- Bilateral air entry normal
Lab Investigation :
- CBC
Radiological Investigation:
- X Ray scan (PA view)
- MRI scan (lateral view)
Post operative NPRS: 3/10
Special test:
• 90-90 straight leg raise: -ve
• FABER Test: -ve
• Lumber extension test: +ve
• Ober’s test
• For neurodynamic test- SLR Test: +ve (60 to 65 degree)
- slump Test
Differential diagnosis
• Disc degeneration
• PIVD
• Spinal canal stenosis
• SI joint arthritis
• Functional scoliosis
• Cauda equina
PROVISIONAL DIAGNOSIS: LBA with L5-S1, PIVD
X-RAY Scan
(PA View):
MRI-Scan :
(lateral view)
DIAGNOSIS: L5-S1
extruded disc and severe
canal stenosis
Problem List:
- Pain in lower back
- Pain during ADL’s
Goal and Treatment
Short term goals:
To - Decrease pain
- Reduce the tightness of lumbar
- Improve ROM
Long term goals:
To – Improve the strength
- Improve the ADL’s
Management
Pharmacological management:
- Muscle relaxant
- Analgesic agent and long acting corticosteroid combination
Physiotherapy management:
Day-1:
- Active assisted ROM Exercise(5 reps * 2 set)
- Heel slide(5reps* 2 sets)
- Ankle toe pumps
- Breathing exercise: Deep breathing exercise
Diaphragmatic breathing exercise
2-3 Days:
- same by increasing repetitions
- In addition, Active straight leg raise
- knee isometric (5reps*2 set)
- Teach positioning as well as rest in semi-fowler position at
least 5min in each 3-4 hrs.
- Pelvic rolling
Advice: place pillow below the ankle (prevent swelling or
oedema)
4-7 Days:
- same by increasing repetitions
- walking with support or without support
- moderate resisted exercise of lower limb and resisted
exercise for upper limb.
- Dynamic quards
Advice: Avoid forward bending during walking and long sitting
THANK YOU
