2. DR. SAHED AL IMRAN
MS Phase A Resident (R8)
Department Of Neurosurgery
Unit IV,DMCH
3. PARTICULARS OF THE PATIENT
Mr. Al Amin
34 years of age
Male, Married ,Muslim
Day labour
Right handed
Non Hypertensive , Non diabetic , Non asthmatic
From Motlob, Chandpur got admitted into DMCH on 15th
this year
4. Presenting complaints
1) Low back pain for 2 years
2) Gradual onset of pain in the calf muscle for 8 months
3) Tingling and numbness in the same region for 8 months
5. History of present illness
According to statement of the patient, he was reasonably well
two years ago. Then he developed low back pain. The pain was
intermittent, mild to moderate in intensity, radiating to back of
the thigh & leg down to the heel on rt side, aggravates during
walking, bending forwards, lifting heavy wt & relieves on taking
rest in lying posture & with pain killer.
6. Contd…..
He also complains of gradual onset of pain in Rt calf muscle for
8 months which aggravates during walking & relieves after
taking rest
16. Motor examination
Upper limb
Normal bulk , tone, power and reflexes bilaterally
Lower limb
Bulk : Normal- both side .
Tone : Normal bilaterally
17. Muscle Power
Right lower limb Left lower limb
5/5 Hip flexion(L2) 5/5
5/5 Knee extension(L3) 5/5
4/5 Ankle dorsiflexion(L4) 5/5
4/5 Extensor hallucis longus(L5) 5/5
5/5 Flexor hallucis longus(S1) 5/5
5/5 Ankle planter flexion(S1) 5/5
18. Motor examination
Reflex :
Right side : Normal knee jerk but diminished ankle jerk.
Left side: Normal knee and ankle jerk.
Planter response : Flexor bilaterally.
Clonus : (Ankle/Patellar ) Absent.
20. There is no cerebellar sign
No sign of meningeal irritation
21. Straight Leg Raising Test (SLR):
Right side: 50 degree
left side: 90 degree
Toe walking – Difficult ( Rt>Lt)
Heel walking – Difficult ( Rt>Lt)
FABER test - Negative
Femoral stretch test - Negative.
22. Local examination of spine
No gibbus
No scoliosis
No deformity
No tenderness
Peripheral Pulses : palpable and normal