Case Presentation 6

Case Presentation 6
Zawin Najah bt Rahim

012013100234
PATIENTS IDENTIFICATION
NAME
: Aruwin Rao
AGE
: 18 years old
GENDER
: Male
OCCUPATION
: Pizza Huts worker
RACE
: India
ADDRESS
: Bandar Puteri
DATE OF CLERKING : 21/10/2016
CHIEF COMPLAINT
Back pain for 3 days
HISTORY OF PRESENTING
ILLNESS
Back pain
Regarding the back pain, it started suddenly 3
days ago when the patient wake up from sleep.
The site is at the lower back specifically at the
center of lumbar spine. Its an intermittent and
stabbing pain that doesnt radiate. However, the
pain is becoming worse which cause the patient to
seek for treatment . Its aggravated by movement
especially when lying down and relieved by taking
2 pills of paracetamol. The pain score was 8/10.
This is the first episode of back pain.
Flank pain
Besides, patient also complain of left
flank pain since the past 3 days. This is
also the first episode of flank pain. The
pain is on and of which started
suddenly. Its characterised by a dull
aching pain that does not radiate. Its
also aggravated by movement
especially when lying down and
relieved by taking paracetamol. The
pain score was 5/10
Fever
The patient also has a history of fever
for 2 days that has subsided. It was
sudden in onset and intermittent in
nature. His body was warm to touch.
There was no documented
temperature and tepid sponging done
at home. The fever was relieved after
intake of paracetamol, which are also
taken to relieve the back pain. The
fever was associated with runny nose
and sore throat with painful
The patient does heavy work such as

cleaning and cooking at his workplace. It
quiets stresses him.
Otherwise, there is no numbness, muscle
weakness or joint paint. There is no change
in walking posture. No rash, no abnormal
bleeding, no nausea and vomiting, no loss
of appetite and loss of weight. There is no
dysuria, no hematuria, no urinary
frequency and foul smelling urine. There is
no history of trauma and injury. The patient
doesnt live in a dengue prone area.
SYSTEMIC REVIEW
GENERAL
No
No
No
No
lethargy
loss appetite
loss of weight
night sweats
CARDIOVASCULAR SYSTEM
No
No
No
No
No
No
chest pain
orthopnea
PND
palpitation
leg swelling
cyanosis
RESPIRATORY SYSTEM
No
No
No
No
No
cough
sputum
hemoptysis
SOB
wheezing
GASTROINTESTINAL SYSTEM
No nausea and vomiting

No change in bowel habit
No hematemesis, melena,
hematochyzia
No jaundice
CENTRAL NERVOUS SYSTEM
No visual or hearing
disturbance
No headache, dizziness or
giddiness.
No muscle weakness
No numbness sensation
No altered behavoiur or slurred
speech
No fits
PAST MEDICAL
HISTORY
There is no past medical history such
as previous UTI. The patient was
never diagnosed with any disease
and being hospitalised before.
PAST SURGICAL
HISTORY
There is no past surgical history
DRUG AND ALLERGY

HISTORY
There is no drug prescribed to the
patient before such as steroid or
anticoagulant
The patient doesnt take any over
the counter medicine, supplement
and traditional medication
The patient doesnt have any allergy
towards any kind of food
FAMILY HISTORY
54 Years
Heart
disease
on tx
47 years
22year
26
27
s
years
years
No history of malignancy running in the family
SOCIAL HISTORY
The patient works in Pizza Hut
He is currently living with his family
He is a smoker since a year ago and
smoke 3 sticks a day
He drinks occasionally and never
take any recreational drug
PHYSICAL EXAMINATION
General Examination
Patient was lying in supine position,
supported by one pillow.
He was pink, conscious, alert and
orientated to time, place and people.
He is a medium built, with good
nutritional and hydrational status.
Vital signs
Blood pressure
Pulse
Rate
Rhthym
Volume
Character
130/80
( prehypertensive)
82 bpm (normal)
Normal
Normal
Normal ( no radio-radial
delay, no radio-femoral
delay, no collapsing
pulse)
Respiratory rate
20 breath per minute
Temperature
37.2
BMI
22
HANDS :
No fine tremor
No peripheral cyanosis
No clubbing, no leukonychia, no koilonychia, no
splinter hemorrhage, capillary refill time <2s
No palmar eythema
No bruises
FACE :
No dysmorphism
Eyes : no scleral jaundice, no conjunctival pallor,
MOUTH AND ORAL CAVITY :

Lip is pink, no angular stomatitis
No loose tooth, no dental caries
Tongue is wet, no coated tongue
No central cyanosis
No oral ulcer
Good oral hygiene
NECK :
No cervical lymphadenopathy
LYMPH NODE
No palpable lymph node
LOWER LIMBS
Both limbs are symmetry and in
normal position
No bilateral pitting edema
No redness, no ulcer, no fungal
infection on both feet
Back Examination
INSPECTION
Patient grimace during changing position from lying down
to standing up
Patient can stand steadily
The gait is normal
The back is symmetry with normal contour
There is no muscle wasting and sacral edema
There is no spinal deformity such as scoliosis or kyphosis
There is no soft-tissue abnormality such as lipoma, tuft of
hair or hemangioma
There is no surgical scar
PALPATION
Spinous process is aligned well
There is tenderness at the level of L3-L4
MOVEMENT
Lumbar flexion
Lumbar extension
Lateral flexion
The patient
movement is
limited due to the
tenderness at both
L3/L4 and lumbar
area(loin)
Abdominal examination
Inspection
Abdomen was flat, not distended and
moves with respiration
Umbilicus is centrally located and inverted
No visible mass, dilated veins & surgical
scars
Palpation
On superficial palpation, the abdomen was
soft.
There is tenderness at the left lumbar area
On deep palpation, there was no
hepatosplenomegaly
No abnormal mass present
Kidneys were not ballotable
Percussion
No shifting dullness and fluid thrill
Auscultation
Normal bowel sound was heard
No bruit was heard
SUMMARY
An 18 year old gentlemen presented with
worsening back pain for 3 days. It is
associated with left lumbar pain. There is
gait abnormality and muscle weakness.
There is no dysuria, no urinary frequency
and urgency and no foul smelling urine.
On PE of the back area, there is tenderness
at the level of L3-L4. On abdominal
examination, there is tenderness at the left
lumbar area.

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Case Presentation 6

Zawin Najah bt Rahim

Back pain for 3 days

The patient does heavy work such as

No nausea and vomiting

CENTRAL NERVOUS SYSTEM

DRUG AND ALLERGY

20 breath per minute

MOUTH AND ORAL CAVITY :

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