MEDICAL
REPORT
N. C, 69 YEARS, FEMALE
WCA/ 6067/2023
Diagnosis: Degenerative Disease of
the Lumbar spine especially on L4/L5 Dermatomes
The above-named is a 69yr old female known but
controlled hypertensive not diabetic presenting today with more than 2yrs
history of insidious onset of low back pains which has become increasingly
radicular predominantly to the left L3/L4 dermatomes. Pain is exacerbated by
standing and walking a distance and relieved by sitting and resting. Worst in
the mornings not associated with bowel or bladder dysfunction. On one occasion
she suffered as acute exacerbation following a domestic fall (slipped on wet
floor). Recently, her walking distance has reduced considerably and thus
affecting her quality of life significantly. This has become a source of
concern for herself and her family. Hence, she is seeking medical help now. It
is also important to note that since her fall and the result in left ankle
injury. The limitation of mobility has greatly contributed to her recent weight
gain and BMI today is 42 which is supposed to be 10-12.
Neurological
Examination
Revealed normal tone, power, reflexes and sensation
on both lower limbs. However, there’s significant limitation in a straight leg
raising due to pain on her low back.
Clinical
Differential Diagnose: Degenerative disease of lumbosacral spine especially
on the L4/L5 Dermatomes On a background of Obesity (High BMI)
Radiological
investigation: MRI of the lumbosacral spine shows
preservation of lumbar lordosis multi-level disc bulges but no prolapse. The
weight of disc spaces are reasonably well preserved. Particularly at L2/L3.
There is encroachment and perhaps entrapment at the intra ventricular foramen
worst on the left but also present on the right. of not is 6.5cm thickness of
subcutaneous fat at the L4/L5 level
From
the fore going problem include
·
Obesity ( BMI 42)
·
Early Degenerative disease of
lumbosacral spine
Management Plan
·
Patient counseled
on diet and life style modification in that effective and smooth weight
reduction down to acceptable BMI
·
Continue physiotherapy
·
KIV lumbar
Epidural injection
·
To see again
in 4weeks time
Kindly revert for further
clarifications if need be.
Sincerely yours
Dr.
Halima Ibrahim
For Team Wellington Clinics.