70F LEG PAINS, BACK PAIN TELANGANA PAJR

23-09-2024

This is an online E Log book to discuss our patient's de-identified health data shared after taking her signed informed consent .

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

In this case the patient is a 70yr old lady suffering with pain in legs and her back.

Since last 6 days she is suffering with pain in legs and soles feel like lumps. A few years back a tumor was removed during the spinal surgery. She had the following treatments done.

1. Burning sensation and  tingling numbness of B/L lower limb.

2. Frequency of urination  - 21yrs.

3. Surgery and tumor removal from lumbar spine region, since which the patient is having weakness of B/L lower limbs.

4. Patient is a known case of hypertension  on tab Telma 40mg. Her 

BP is 150/80.

ADVICE TO THE PATIENT 

- Hemogram

MRI- C. Spine

Whole spine screening 

Neuro opinion 

LFT, RFT

HBA1C 

USG WA

ADMIT IN FMW, GM- I, DR. MANOJ

MEDICATION TO THE PATIENT 

1. Injection Optineuron 1 amp + 500ml

    NS IV OD (After AST)

2. Tab Pregaba - NT 1 HS

3. Tab Shelcal - XT 1 OD

4. Tab Telma - H 1 OD/ AC

1. Tab Pregabalin 75 mg X-X-1  15 days

2. Tab Amytriptyline 10mg X-X-1 15days

3. Tab Telma - H (40+12.5) 1-X-X 10 days

4. L- S - Belt.

25-09-2024

PA - Sir the patient is suffering with pain in her lower limbs since last 6 days. Her soles feel like lumps and having tingling numbness in her lower limbs. Should the patient continue with the medicines?

PPM - Please ask her to continue.  This tabs will start working slowly in a few weeks.  Please continue them and we can also slowly increase their dose depending on the response shared here. For current  pains she can take Ultracet  half tablet every 6 hrs for two days. If not available she can take paracetamol  650 mg every 6 hrs for 2 days.

27-09-2024

PA - Sir we are not getting the tablets in the medical shop.

PPM - Yes it requires  a prescription in our OPD slip. Alright then let her take paracetamol 650mg every 6 hrs for 2 days.

PA - Sir good morning. The patient is feeling lumps in her soles. She is having

 pain in the hands, legs and knees. She is losing grip on objects due to lack of strength and pain in her hands. The paracetamol 650mg which you prescribed is not effective for her.

PPM - Is she doing regular physiotherapy? That's particularly very important for her recovery.

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