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SEMEY STATE MEDICAL UNIVERSITY

PATIENT’s Name
ISMAILOV ASGAR
AGE-----18 years.

Osteochondrosis of the lumbar region.chronic residive


course,exercerbation,lambalgia, chronic maxillary sinositis, stage of remission.

STUDENT:Raja Ali Hassan


GROUP: 524
DATE OF EXAMINATION
November, 18, 2010

KAZAKHSTAN, SEMEY 2010


GENERAL ITEMS OF INFORMATION ON PATIENT

I.PASSPORT PART.
1-NAME: Ismailove Asgar.
2- AGE: 18yrs old.
3- SEX: Male
4- NATIONALITY: Kazak
6-PROFESSION: works in Army
7-CONTACT RESIDENCE: Semey
8-DATE OF ADMISSION: 15-11-2010.
9- DIAGNOSIS OF HOUSE DOCTOR: Lumbar Osteochondrosis, chronic form with
exacerbations. Chronic maxillary sinositus.
10-PROVISIONAL DIAGNOSIS: Lumbar Osteochondrosis, chronic form with
exacerbations. Chronic maxillary sinositus, Vertebral syndrome.

11-CLINICAL DIAGNOSIS, : Osteochondrosis of the lumbar region, chronic


residive course, aggravated (exacerbated).Lambalgia Vertebral nerve
Syndrome. Chronic vertebrobasilar insuficiency. Cavernous angioma, foci at
the right hemisphere at the level of internal capsule.

I. PATIENT’S COMPLAINTS AND THEIRS CHARCTERISTIC.


1. A: Pain
2. Localization: Headache in the frontal area.
3. Intensity of Pain: Sharp pain.
4. Character: Shooting pain in the frontal area.
5. Duration of pain: Attack of pain for 5 minutes with the rate of 10-17 times shooting
ache in frontal area.
6. Headache arises at anytime of the day.
7. Headache is provoked, and cause of it is sinusitis.
8. Headache is never associated with the Vomiting and nausea.
9. There is no connection of nausea and vomiting with the feeding.
a. B:Vertigo:
b. Vertigo is not present in the patient.
c. C: Disorder of motor function:
d. All movements are intactin all four limbs.
e. E: Sensory Disturbance:
f. All of the senses are preserved.
10. F: There is no cranial nerve disorders, memory is good, sleep is also good and
speech is totally adequate without any pathological disorder.

III. PAST MEDICAL HYSTORY.


According to the patient he has been ill since last one week of November 2010. The initial
symptom was pain in the lumbar sacrum site. The pain arised at rest. There are the
preceded or concomitant (associated) symptoms such as vertebrogenic syndrome.
The diseases’ course: is attack-like.
Previous treament: ambulant (outpatient) treatment was of no advantage.
Medical managements which were used earlier: the medicinal preparations had not used
earlier.
The diagnostic investigations: had not been done before hospitalization.
Before coming to central hospital no.3 patient was urgently hospitalized in army hospital
and he was there for 1week.
V. PERSONAL (LIFE) HISTORY.
The patient has osteochondrosis of the lumbar region at chronic form. The patient got this
disease just 1 week before. He had maxillary sinusitis and due to this sometimes he used
to have headache. When patient was 17 yrs old he had appendectomy. He has not taken
any medications. The patient had been admitted to the army hospital before with the same
disease for one week. Influence of the job nature to the main disease is not seen because
the patient didn’t lift anything heavy. Patient is a chronic smoker and hes been smoking
since last seven years.

V. THE HEREDITY: The patients father and mother have no disease.

VI. Allergic anamnesis: The patient had not been suffering from any allergic disease and
had no allergy of any kind from any of the drugs or daily usage stuff.

VII. Epidemiologic anamnesis: the patient had not been incontact with any other patient with
acute febrile diseases or other infections.

VIII. SOMATIC STATE: General state of the patient is good and consciousness is clear
15points by Glasgow Scale.
Patient’s position: Active.
The skin and visible mucous membrane are without any pathologic findings. The
peripheral
lymphatic nodes are palpable. Changes from the side of the locomotors apparatus as
scoliosis not seen at all spinal levels.
RESPIRATORY APPARATUS: Respiration is free. Respiration rate is 17/minute.
Breathing is vesicular, no crepitations. Sometimes patient complains of cough due to
smoking.
CARDIOVASCULAR SYSTEM: Heart sounds are well heard. B.P: 130/ 80 mmHg. Pulse
rate is 71 beats/minute.
DIGESTIVE (ALIMENTARY) SYSTEM: Swallowing is free. The tongue is clean. Palpation
of the gastrointestinal tract shows no pathologic findings.
The gall bladder percussion is without pain. A stool regular.
GENITOURINARY APPARATUS:
Polyuria is present.
ENDOCRINE SYSTEM:
the patient has no endocrinological disorder.
IX.NEUROLOGIC STATE: Presence of the common cerebral symptoms. There is no
meningeal signs .
Cranial nerves:
• I-st CN.Olfactory nerve; Sense of smell from both right and left sides is alive.
• II-nd CN. Optic nerve: Trichomatsia. Visual acuity is 6/6, papillary reflexes are
preserved.
• III-d, IV-th, VI-th CN: no ptosis seen, no en- or exophthalmos. Pupil is round, black
and size is equal in both eyes.

Ocular motility: No miosis and nystagmus.


• V-th CN: pain perception over the tree division and on the “onion” area (ring area)
is not noticed.
• Assess the corneal and conjunctival reflexes (each eye separately). Condition of
the
• mastication muscles is considerable, masseter and
• temporalis muscle bulk is regular on both sides of the face.
• VII-the CN: the general impression of the patient’s face shows normal
• motility and emotional expression. forehead wrinkling, eyelid closure,
• Mouth retraction, and labial articulation; are symmetrical on both sides of the face
too.
• VIII th CN: the patient’s ability to hear conversational speech, a tuning work, a
watch tick, and rustling of fingers shows the threshold and acuity in average
ranges.
• IX-th, X-th, XII-th CN: Speech – the patient doesnt display any of the following
impairment
• of speech; A) Dysphonia –difficulty in producing the voice sound. B) Dysarthria –
difficulty
• In articulating.
• The tongue is not atrophied and is without any fasciculation.
• Taste in anterior 2\3 of tongue is fine.
• XI-the CN: sternocleidomastoid and trapezius contors are not seen.

MENTAL STATUS.
• General behavior and appearance: the patient’s behavior is active.

• Flow of speech: the patient’s conversation is normal, and the degree of spontaneity
is good.
• Mood and affective responses. the patient is emotionally silent.
• the patient’s mood matches the subject matter of the conversation.
• Content of thought: the patient does not have illusions, hallucinations, or delusions.
• and the patient doesn’t display phobias or preoccupation with bodily functions.
• Intellectual capacity. the patient is bright.

MOTOR SYSTEM.
Inspection: the patient’s somatotype, posture, general activity level are fine and there are
no tremors seen, and there were no other involuntary movements.
The size and contour of the muscles didn’t show any atrophy, hypertrophy, body
Asymmetry, joint contracture or the fasciculations.The patient’s gait is free walking.
Strength (power) testing:
1.Shoulder girdle; scapular winging is not seen.
2.Upper limbs; the strength of biceps, triceps, wrist dorsiflexors, and grip is fine and the
strength of fingers abduction and extension is similar on both of hands.(normal strength)
3.Abdominal muscles; umbilical migration is not spotted.
Muscle power: grade 5.
Percussion : No myotonia noticed at the thenar eminenses.
Muscle tone assessment : No hypotonia, no spasticity, clonus seen and no rigidity.
Muscle stretch (deep) reflex testing:
1. Jaw lerk (CN V afferent, CN V efferent).
2. Biceps reflex D=S
3. Triceps reflex D=S
4. Radial reflex D=S
5. Knee reflex D=S
6. Achille reflex D=S
Superficial reflex testing.
1.Abdominal skin-muscle reflexes). Alive
2.Cremasteric reflex : alive
3.Anal reflex: alive
SENSORY SYSTEM.
Pain is aching at the lumbar region. Pain evoke at any time.
Vertebral syndrome : muscle rigidity (muscle spasm) on the lumbar area, lordosis found at
lumbar spine,no limitations of the back motility to the or right to the
left.
leg raising tests: straight-knee leg raising test (Lasegue’s sign) for each leg show no
pathological findings.
Forced (anthalgic) posture and contracture is not seen. Palpation along vertebral column
reviels no pain. Pain by percussion of the cranium and backbone shows no pain.

CEREBELAR FUNCTION.
• The gait of patient is free walking.
• The finger-nose test: no missing without intension tremor.
• Stability in Romberg’s posture.
• Babinski’s raising-up test: patient can sit without help of his arms.
• Test for adiadochokinesia: the patients movements moderate and complete.

X .Syndromologic diagnosis.
• Common brain syndrome.
• Vertebral syndrome.
• Focal syndrome.

XI. The Provisional diagnosis. Lumbar Osteochondrosis, chronic residive form with
exacerbation, lumbalgia, Chronic vertebral syndrome, chronic maxillary sinusitis.
XII. The sequential plan of manegment: investigation plan, treatment plan.
• General clinical analysis.
• CT scan.
• Streatch test.

XIII.Results of laboratory and accessory instrumental studies

General clinical analysis:


Blood test;
A: Hb- 127 g/l
B: Erythrocytes: 4.31 - 10*12/l
C: Leucocytes: 3.99 – 10*9/l
D: Nuclear sedimentation rate- 62- 10*9
E: ESR – 3 mm/h

Biochemical blood analysis:


A: Glucose-4.9 mmol/l
B: Cholestrol LDLP- 3.15 mmol/l
C: Cholestrol HDLP- 1.33 mmol/l
D: Triglycerides- 0.57 mmol/l
E: Common Cholestrin level: 5.0 mmol/l

ECG:
Sinus rhythm with the heart rate of 71/min. Horizontal axis. Hyperactivity of left ventricle.
XIV Topical diagnosis
Osteochondrosis of lumbar region.

XV.Final clinical diagnosis;


1. Predominant diagnosis. Osteochondrosis of lumbar region.
Osteochondrosis of the lumbar región chronic residive form, aggravated
(exacerbated).Vertebral syndrome, lumbalgia, chronic maxillary sinusitis.

2. Complication of predominant diagnosis. Dyscirculatory encephalopathy 2nd stage.


3. Associated diagnosis. Dyscirculatory encephalopathy 2nd stage. Arteriosclerosis of the
cerebral artery. Angioma of the internal capsule in the foci of right hemisphere. Mild
Hydrocephaly.

XVI.Treatment:
1. Bed rest on a firm mattress.
2. Analgesics’: non-steroidal anti-inflammatory agents: asprin 7.5mg 1 pill 2 times/day for
2 weeks.
3. Lumbar spine traction.
5. Vitamin therapy: vitamin B12.
6. Dehydration.
7. Vasoactive therapy.
8. Physiotherapy, gymnastic, massage, acupuncture therapy.

XVII .Diaries:
1. I checked the patient at 18-11-10 at 12:15 pm, the patient’s condition was good,
and the pulse was 75/min, B.P was 125/80 mmHg.
2. I checked the patient at 19-11-10 at 10:10 am. The patient’s condition was good
and the patient was happy for the treatment he was getting. His consciousness was
active and all of the reflexes were alive.
3. I checked the patient at 20-11-2010 at 1:00pm, I checked his B.P it was
120/89mmHg,
XVIII.Epicrisis; It is written accoding to scheme:
1. Patient is in hospital since 15 -nov -2010.
2. Diagnosis:
3. Osteochondrosis of the lumbar region, chronic residive form,
aggravated (exacerbated).Vertebral syndrome, lumbalgia, Chronic
vertebral syndrome, chronic maxillary sinusitis.

4. Patient’s complaints by entrance are the aching pain in the lumbar


region. By clinical examination in state of patient there was
osteochondrosis of the lumbar region, chronic residive form, lumbalgia.
5. By accessory studies there are vertebral syndrome, common brain
syndrome and lumbar osteochondrosis.
6. Dynamics condition of patient since the beginning of treatment is
Positive.
7. Recommendations:
8. Consultation to the neuropathologist is obligatory and he must have
check up every month.
9. XIX. Prognosis for life and for ability to work.
10. the patient’s physical condition is improving and there is good response
to medication medications he is in a good health now.