MRI of the Lumbosacral Spine (Screening Protocol) 03/09/12
Findings
Mild loss of normal lumber lordosis is seen, which may be secondary to muscle spasm, Disc dehydration seen at L4-L5 at this level there is a mild diffuse disc bulge causing anterior thecal indentation with mild encroachment of the neural foramina on either side. No evidence of spinal canal stenosis is seen. The caudae equine and filum terminale is normal. The paravertebral soft tissues are normal. No fact joint abnormality is seen. The vertebral bodies shows no abnormal to indicate bone marrow replacement.

Complete blood count & ESR Result Normal range 02/09/12
Hemoglobin 12.5 13.16.3 g/dl
Haematocrit (PCV) 38.0 40.50 %
Erythrocytes (RBC) 4.87 4.5-6.0 mil/ml
MCV 80 76 – 96 FL
MCH 27 27 - 32 pg
MCHC 32 30 – 35 pg
Total leucocytes count (WBC) 9,500 4,000 – 11,000 cmm
Differential Count (DLC)
Neutrophils 59 40 – 75 %
Lymphocytes 36 20 – 45 %
Eosinophils 03 01 – 06 %
Monocytes 02 02 – 08 %
Platelet count 430,000 0000 – 0000 cmm
ESR 18 0 – 20 mm/hrs
Remarks Normochromic / Normocytic.

25 – Hydroxy Vitamin D Level 02/09/12
Remarks:
Interpretation:
Normal levels (Optimal) = > 30.0 ng/ml
Result: 15.9
Vitamin D deficiency:
Deficiency = > 10 ng / ml
Insufficiency = > 10.30 ng /ml
Sufficiency = > 30 ng/ml
Toxic level = > 100.0 ng/ml
Note: differences in vitamin D3 levels may exist with respect to gender, age, season,
Geographical latitude and ethnic groups.
X-Ray of Lumbosacral Spine (AP/Extension / Flexion)02/09/12
Disc height is reduced at L5/S1
Osteophytes seen at L5 vertebral body.
No significant interior or posterior subluxation seen in the extension and flexion views.
Degenerative changes also seen involving both sacroiliac joints.
Soft tissue densities appear normal.
Conclusion:
Spondylitic changes seen predominantly at L5/S1.
Disc height is also reduced at this level.
No anterior or posterior subluxation is seen.

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