19th
April, 2023
MEDICAL
REPORT
T.J, 60 YEARS, MALE
WCA/6147/2023
BACKGROUND INFORMATION
A 60 year
old man who was referred by Rev Fr James Ekpai and presented today with
complaints of recurrent lower back and recurrent chest pain of 1year duration.
He
describes his back pains as insidious in onset, shocking and electrifying,
sharp, radiates to the buttocks and both lower LL (severe on the left), relieved by most likely opoids, worsened by
prolonged sitting, severe enough to interfere with sleep, severity of pain is
10/10. No hx of trauma, no family hx of BPH or Prostate cancer.
Chest
pain is left sided, insidious in onset, sharp in nature, non radiating,
relieved by pain killers, worsened by prolonged sitting, severe enough to
interfere with activities. No hx of cough, dyspnea, fever, blurring of vision,
abdominal pain or other GI symptoms, no hx of urinary symptoms.
He is a
known hypertensive. However, patient does not agree to be diabetic, despite
previous confirmed clinical investigations. Also, he was diagnosed with
Sciatica and Lumbar spondylosis 2 years ago.
PHYSICAL EXAMINATION: An elderly man walking with a
stick, afebrile (36.5C), not pale, aniceteric, not dehydrated, acyanosed, no
pedal edema.
Weight-
119kg, BMI-34kg/m2
NEURO EXAM: Confirms limitation of straight
leg raising on the left lower limb. Tone and power are normal globally. Fine
touch sensations are impaired in both foot.
CVS: BP- 138/90mmHg, HS- 1&2 +murmur
MANAGEMENT PLAN;
1. Lumbosacral MRI and CXR
2. FLP, ECG, EUCR, HbA1c, RBG, FBC.
3.
Counsel patient on his condition
4.
Lifestyle modification, weight
reduction, and diet.
5.
Tabs cerebrex 200mg b.d x 2/52
6.
Tabs Omeprazole 20mg dly x 2/52
7.
Tabs pregabalin 75mg b.d x 2/52
8. See in 3 months time (20/07/2023)
Review
of MRI Lumbosacral spine confirms an advanced disc
degenerative disease at the L4/L5 level with an associated disc herniation
especially postero-laterally and bilaterally causing compression/entrapment of
exiting/transversing nerve roots. There is also slight indentation of the cauda
eqina at that particular level.
It is believed with a high degree
of certainty that there is clinical radiological concordance.
LABORATORY
INVESTIGATIONS:
RBS- 6.21mmol/L
HbA1c- 6.7%
Lipid profile- Cholesterol- 180.4,
TG- 28.70, HDL- 26.58, LDL- 148.08
EUCr- Na-139.5, K-3.77, Cl- 110.5,
Urea-27.74, Creatinine- 0.69
FBC- WBC- 4.34, HCT-49.24%, PLT-256
RECOMMENDATION:
We
recommend that the patient will benefit from an epidural injection which is a
cocktail of 80mg triamcinolone + 2.5mls of 0.25% marcaine. The aim is to tide
him over the period that he is trying to achieve the recommended weight
reduction for pain management.
Kindly
revert for further clarifications if need be.
UPDATE (21/04/2023)
Epidural
injection of cocktail of 80mg triamcinolone + 2.5mls of 0.25% marcaine was
administered to this patient in the operating room. Both written and oral consent
was taken from the patient before the epidural injection was given. Post
operative condition was satisfactory.
Above
are images from the C-arm machine that injection was given into the epidural
space.
Yours
sincerely,
Dr. Modupeoluwa
Olakunle Motajo
For Team
Wellington Clinics
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