30 M L5-S1 INFECTIVE SPONDYLODISCITIS

 30 year old male driver by occupation came to orthopaedic OPD with chief complaints of low back pain since 8 months.


HOPI : 

PATIENT WAS APPARENTLY ALRIGHT 8 MONTHS AGO THEN DEVELOPED PAIN IN LOWER BACK WHICH IS INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE AGGRAVATED BY STANDING, WALKING, SLEEPING, HEAVY WEIGHT LIFTING AND NO RELIEVING FACTORS SINCE 1 MONTH ASSOCIATED WITH RADIATING PAIN TO LEFT LEG 

H/O LOSS OF WEIGHT PRESENT IN LAST 8 MONTHS 

H/O FEVER since last 8 months low grade not associated with chills and rigors


PAST HISTORY : 

N/K/C/O HTN,DM, TB, ASTHMA,EPILEPSY,THYROID,

H/O ORIF+PLATING FOR LEFT THIGH 10 YEARS AGO, IMPLANTS REMOVAL 3 MONTHS AGO


PATIENT IS CONCIOUS , COHERENT , COOPERATIVE

BP - 120/80 MMHG

PR - 78 BPM

RR - 16 CPM 

SPO2- 98%

TEMP -98.7 F

CVS - S1 S2 HEARD

RS - BAE +, NVBS HEARD 

PIA - SOFT AND NON TENDER 

CNS - NFD


LOCAL EXAMINATION OF SPINE

SKIN - NORMAL

SWELLING - ABSENT

LOCAL RISE OF TEMPERATURE present 


LOCAL RISE OF TEMPERATURE - PRESENT

RIGHT LEFT

SLRT 90 90

POWER

HIP

FLEXION 3/5 5/5

EXTENSION 3/5 5/5

KNEE

FLEXION 5/5 5/5

EXTENSION 5/5 5/5

ANKLE

DORSIFLEXION 5/5 5/5

PLANTAR FLEXION 5/5 5/5

EHL 4/5 5/5

FHL 5/5 5/5

SENSATIONS INTACT INTACT

DISTAL PULSES PRESENT PRESENT

REFLEXES

TRICEPS + +

BICEPS + +

SUPINATOR + +

KNEE ++ ++

ANKLE ++ ++

Right PLANTAR FLEXION 

LEFT PLANTAR FLEXION



INVESTIGATIONS : 


COMPLETE BLOOD PICTURE (CBP) 12-04-2024 

HAEMOGLOBIN10.9 gm/dI

TOTAL

COUNT5500 cells/cumm

NEUTROPHILS50 %LYMPHOCYTES41 %EOSINOPHILSO2

%MONOCYTES07 %BASOPHILSO %PLATELET COUNT3.08

SMEARNormocytic

normochromic

COMPLETE URINE EXAMINATION (CUE) 12-04-2024 

COLOUR- pale yellow APPEARANCEClear

REACTIONAcidic

SP.GRAVITY1.010

ALBUMINNiI

SUGARNiI

BILE SALTSNIIBILE PIGMENTSNIL

PUS CELLS2-3

EPITHELIAL CELLS2-3

RED BLOOD CELLS NIL CRYSTALS NiI CASTSNiI 

AMORPHOUS DEPOSITSAbsent

OTHERSNiI

SERUM

ECTROLYTES (Na, K, C 1) 12-04-2024 SODIUM138 mmol/L

POTASSIUM4.2 101/L

CHLORIDE101 mmol/L



LIVER FUNCTION TEST (LFT) 12-04-2024  Total rubinO.79 mg/dI

Direct Bilurubin0.25 mg/dI

SGOT(AST)13 IU/L

SGPT(ALT)17 IU/L

ALKALINE

PHOSPHATASE187 IU/L

TOTAL PROTEINS6.6 gm/dI

ALBUMIN3.3 gm/dI











PATIENT WAS CLINICO RADOLOGICALLY DIAGNOSED AS L5 S1 INFECTIVE SPONDYLODISCITIS, ON 13/4/24, UNDER ALL ASEPTIC CONDITIONS, TRANSPEDIC BIOPSY WAS TAKEN UNDER LOCAL ANAESTHESIA, PROCEDURE UNEVENFULL. C BIOPSY SAMPLE WAS SENT FOR CULTURE SENSITIVITY WHICH HAD KLEBSIELL PNEUMONIAE ISOLATED AND SENSITIVE TO GENTAMYCIN, COTRIMOXAZOLE, CIPROFLOXACIN, CEFTAZIDIME, CEFOTAXIME, PIPERACILLIN/TAZOBACTUM, AN

MEROPENEM. ATT WAS STARTED ON 16/4/24.






Patient was being discharged on 18-4-2024 

in hemodynamically stable condition and advised to continue ATT and take complete bed rest.

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