57/F with low back ache

Case:
A 57year old female came with chief complaints of
- Low back ache from 10 years
-Excessive lacrimation from 10 days
-Epigastric pain from 10 days
HOPI:
Patient was apparently asymptomatic 10 years ago , then she fell from steps and after 1 year she has back ache and went to hospital in bhopal  where she was given medications and 4 years ago she again fell on road and went to hospital in Hyderabad where she was given lumbar support belt and medications,now she came with low back ache, squeezing type , radiating to both lower limbs
- Excessive lacrimation from 10 days
-Epigastric pain from 10 days,burning sensation
Past history:
K/C/O HTN ,not on regular medication
No DM,Asthma, Epilepsy,TB,CVA,CAD
Present history:
Appetite:Reduced
Diet :Mixed
Sleep : sleeplessness  at night from 6 months
Bowel and bladder habits -Regular
Addictions :Chews betel leaf  6-7 / day from 35 years
General Examination:
patient is conscious, coherent, co-operative, well oriented to time, place and person
Moderately built and nourished
No pallor, icterus, cyanosis , clubbing,pedal oedema, lymphadenopathy
Vitals:
PR:80
BP:120/80mm Hg
Temp:98.1 F
RR:14cpm
Systemic Examination:
CVS: s1s2 present,no murmurs
RS: BAE Present,NVBS
P/A: Soft,non tender
CNS: NAD
X-ray spine



ECG


Ortho referral
Opthalmology referral 













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