Presenting Complaints • LBA radiating to both leg • Pain and numbness on lower limb • Heaviness of head • Itching on right foot

Mr: :Sameer muraddid H Alsirwani 43 yrs. old /M admitted here with concern of LBA ,Pain and numbness on lower limb ,heaviness of head and itching and skin complaint on right foot. Pain and numbness on lower limb aggravated on crossed leg sitting position and he feel better on activity and LBA aggravated on lying hard surface.

1. DISCHARGE SUMMARY

NAME OF PATIENT:Sameer muraddid H Alsirwani CONSULTANT: Dr.Mohamed Mubashir
AGE:43/M DOA:7/06/24 DOD: 27/06/24
ADDRESS: Saudi Arabia
Presenting Complaints
 LBA radiating to both leg
 Pain and numbness on lower limb
 Heaviness of head
 Itching on right foot

History of Presenting Complaints:
Mr: :Sameer muraddid H Alsirwani 43 yrs. old /M admitted here with concern of LBA ,Pain and
numbness on lower limb ,heaviness of head and itching and skin complaint on right foot. Pain and
numbness on lower limb aggravated on crossed leg sitting position and he feel better on activity and
LBA aggravated on lying hard surface.
INVESTIGATION:
MRI LUMBO SACRAL SPINE (20/06/24):
 Lumbar spondylotic changes
 At L4-L5 level -mild disc desiccation and mild diffuse buldge indents the thecal sac . Left
foraminal protrusion narrows the left neural foramen and abuts the left L4 exiting nerve root
 At L5-S1 Level -mild desiccation and mild diffuse buldge indents the thecal sac abuts the left S1
tranversing nerve root. mild left foraminal protrusion narrows the left neural foramen and abuts
the left l5 exiting nerve root.
 Tarlov cyst noted at S2-S3 levels
.Diagnosis: Modern & Ayurveda
 IVDP
 Gridrasi
 Vatavyadi

2. Ayurveda Treatments Done: Purvakarma / Panchakarma
Dep : PANCHAKARMA
1. Udwarthanam
2. Danyamla dara
3. Jambeera pinda swedam
4. Danyamla kizi
5. Manjal kizi
Dep: INTERNAL MEDICINES
1. Amrithotharam ks 15 ml bd
2. Kaisora guggulu 1 bd
3. Avipathy churnam 1 tsp hs
4. Cap misrakam Sneha 1 hs
5. Rasna sapthakam ks 15 mk bd
6. Tab vilwadi 1bd
7. Vasa guluchyadi 15 ml bd
8. Cap nimbamritha erandam 1 hs
Dep: PHYSIOTHERAPY
On Initial Assessment
 LBA –(VAS-6/10)
 Radiating pain at bilateral lower limb
Treatments:
 Pelvic traction
 IFT
 Strengthening programme

Improvement / Condition of patient @ discharge
 LBA Reduced (VAS-2/10)
Advises:
 Continue home program exercises
 Avoid carry heavy weight
Discharge Medicine:
1.Sahacharadi ks tab 2 bd
2.Tab manasamitra vatakam 1 bd
3.Murivena Extenal application

3. Advices @ Discharge:
Dep: PATHYA & APAHTYA (Dos & Don’ts)
 Patient Advice to take the given Medication on Time.
 Try to be regular in Sleep, Wake-up, Meditation / Prayer, Food Habits & Elimination etc.
Diet & Life style
 Use Easily-digestible food, Green gram, Lime juice, Butter milk etc
 Use Well-cooked food, Green Leafy Vegetables, Vegetable & Fruit Salads.
 Drink only Warm Water, better boiled with Ginger, Jeera etc.
 Avoid Normal or Cold Water, Colas & Cold Beverages.
 Avoid Heavy food, Excess Oily and Spicy Food & Fermented food.
 Avoid (incompatible foods): Milk & Milk products like Curd / Milk tea, Milk coffee along with
Fishes & Non-veg foods.
 Avoid Curd: prefer Butter Milk with Ginger, Curry Leaves and Garlic etc crushed in.
 Limit non-veg foods / use Pineapple or Lemon or both along with non-veg foods for better
Digestion.
 Avoid Deep Fried non veg foods, instead prefer food with Less oil / directly heat treated like
Alfaham , Kabab & Barbecue etc
 Avoid overeating & eating without appetite.
 Avoid keeping late nights, irregular habits of sleeping like sleeping immediately after meals.
 Better to do slow walk after meals.


Follow up: Review after 3 months.





Dr. MOHAMMED MUBASHIR T.C
MEDICAL DIRECTOR