Chief complaint: Low back pain for half a year, aggravated 1 day. Current medical history: The patient's left lower back pain radiated to the left hip, the back of the left thigh, the lateral leg and the foot half a year before admission, and the pain was aggravated when coughing and sneezing. I went to the county hospital to take a CT scan of the lumbar spine and showed "L5-S65,438+0 intervertebral disc protrusion (center left)", and was given massage and oral western medicine. 65438+ 0 days before admission, the above symptoms were aggravated again because of bending over to move things, and there was no low fever, night sweats, emaciation, fatigue, incontinence, etc. After being treated in a private outpatient clinic outside the hospital (the specific diagnosis and treatment situation is unknown), there is no obvious relief of low back and leg pain. So today, he sought treatment in the spine clinic of our hospital. The clinic plans to be admitted with "lumbar disc herniation". Chen Xia: The left waist extends to the left lower limb, and the pain is fixed. It is not suitable to throw sideways. Pain refuses to be pressed, the day is light and the night is heavy, and the night sleep is uneasy. Past history: no history of infectious diseases such as hepatitis, tuberculosis and typhoid fever, no history of trauma surgery and blood transfusion, no history of drug and food allergy, and unknown history of vaccination. Personal medical history: born and raised in the country of origin, no history of contact with "epidemic water" and long-term residence in other places, living and working conditions in general, denying the contact history of toxic and radioactive substances. No bad hobbies such as alcohol and tobacco. Physical examination T 36.5℃ P 85 times/min R 20 times/min BP 120/80mmHg conscious, pale, medium build, moderate nutrition, clear voice and no special breath; Clear-headed, painful face acute, normal development, moderate nutrition, automatic posture, physical examination cooperation; No yellow staining and bleeding spots were found in the whole skin and mucosa; The superficial lymph nodes of the whole body did not touch swelling; No deformity of skull, no edema of eyelid, no yellow staining of sclera, no pallor of conjunctiva, no secretion of external auditory canal, no tenderness of mastoid process, no deviation of nasal septum, no cyanosis of lips, no congestion of pharynx and no enlargement of tonsils; The neck is soft, the jugular vein is not dilated, the trachea is centered, and the thyroid gland is not enlarged; There is no abnormality in the chest, the bilateral respiratory movements are stable, the tactile tremor is normal, there is no pleural friction, the lungs are clear, the breathing sounds are clear, and no dry and wet rales can be heard; There is no protuberance in the precordial area, no enlargement of the cardiac boundary, 85 beats/min heart rate, regular rhythm and no murmur in the auscultation area of each valve; The abdomen is flat and soft, with no tenderness and rebound pain in the whole abdomen, no liver and spleen under ribs, no moving dullness, no knocking pain in both kidneys, normal bowel sounds and no vascular murmur; There is no deformity of external genitalia of anus; Details of spine, no swelling and deformity of joints of limbs, and no edema of both lower limbs. Physiological reflex, no pathological reflex, negative meningeal irritation sign. The tongue is purple and dark, and the pulse is astringent. Specialist information: Scoliosis, lumbar protrusion to the right, obviously limited lumbar movement, especially flexion, obvious tenderness in the space between L5-S 1 spinous process and the left side 1cm, which radiated to the left lower limb, left straight leg elevation test (+), and intensive test (+). Auxiliary examination: lumbar CT: L5-S 1 disc herniation (left middle). Physician's suggestion: Admission for observation.

I wonder if I can help you.