SPINE: History Taking (Long Case)

My patient Mr. X son of Mr. Y, 40 years old male, farmer by occupation, resident of Z, presented with the Chief Complaints of

1. Pain in the lower back for 1 year
2. Weakness of both lower limb for 1 year
3. Loss of sensation in the right lower limb below groin for 6 months
4. Difficulty in/ loss of control over passing urine & stools for 2 months
5. Deformity of lower back for 2 months

HOPI (History of Presenting illness)- As stated by the patient/parents

He was apparently asymptomatic 1 year back when he developed PAIN over lower back which was insidious in onset, gradually progressive, continuous/intermittent, mild to moderate in intensity, pricking/stabbing/shock type in nature, non-radiating, aggravated by weight bearing/activity/ coughing and sneezing, relieved by taking rest and oral medications. No diurnal or seasonal variation.

Patient developed WEAKNESS of the both lower limbs one year back which was sudden in onset, following trauma/ fall from bike/ wt lifting, affecting both lower limbs simultaneously, gradually progressive, within 2 months pt was unable to even move the limbs. There was no involvement of upper limbs.

Patient also noted LOSS OF SENSATION of temp/pain in right lower limb below groin. There was no sensation of constriction, zone of hyperalgesia, and sensations of pins and needles/walking on cotton wool.

Patient also complaints of RETENTION/ INCONTINENCE of urine and precipitancy/ hesitancy/ history of catheterisation & burning micturition or impotence. Also there is h/o diarrhoea/ constipation Or bowel incontinence.

Patient's relatives noted CHANGE IN THE POSTURE i.e. forward stooping/ bending of trunk while walking. Patient also noticed a DEFORMITY over the mid back 2 months back while taking bath. It has increased in due course of time.

For these complaints patient took TREATMENT from a Local medical practitioner in the form of oral medications, but got only partial relief of his symptoms so he consulted this hospital 4 days back. Here some investigations were done & treatment was given in the form of bed rest/ traction/ oral and injectable medications.

Patient reports relief in his symptoms after coming to this hospital.

• There is No History Of trauma / lifting heavy object
• There is no history of Fever, chronic cough, appetite loss, weight loss, evening, night sweats and night cries, contact with tuberculosis pt.
• No history of other joint involvement, morning stiffness
• No history suggestive of Genitourinary, Respiratory & Thyroid related complaints.

At Present patient is unable to stand/walk even with support, he is able to sit.

Presently patient’s urinary bladder has been catheterised/empties the bladder with self catheterisation & pt uses bed pan to pass motions.

PAST HISTORY 

• There is no history of TB, asthma, DM, HTN
• No history of any hospital admissions or surgery in the past No h/o similar complaints in the past.

MENSTRUAL HISTORY

• LMP was XXXX, cycles are regular

DEVELOPMENTAL HISTORY

• Patient is 1st born child, it was a supervised pregnancy with regular antenatal checkups, delivery was normal vaginal done at home/ by LSCS in hospital, pt was a full term/preterm baby, cried immediately after birth, did not required any NICU admission
• Patient is fully immunised till date and developmental milestones are normal.

FAMILY HISTORY

• No h/o DM, HTN, asthma, tuberculosis/ similar complaints in the family

PERSONAL HISTORY

• Patient is vegetarian/non-vegetarian, he complaints of reduced appetite, sleep is reduced, history suggestive of bowel bladder dysfunction is present, there is no addiction, patient belongs to lower socioeconomic status.

Credits: Dr. Ashutosh Dwivedi & Dr. Sameer Qureshi.

P.S.- "In this post we have presented a History Taking Sample for a patient with complaints related to the Spine (Long Case). It is advised to practice this sample case multiple times as it covers most of the patient's complaints that a student usually encounters in the Exit Exams."