41 YEAR OLD MALE WITH PAIN IN LEFT LEG

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

This is a case of a 41 year old male with chief complaint of left leg pain since 4 years.

History of presenting illness

Patient was apparently asymptomatic 4yrs ago, then,he developed joint pain starting from left pubic area which was radiating towards the whole left leg(from hip joint to ankle joint) on movement and resting for period of 10-20 mins associated with fever of temp 100-101°F which subsided upon resting.

He developed numbness in the left leg for a period of 20-30 mins whenever the pain was more with loss of touch sensation.

He developed pain in left shoulder while applying pressure since 6 months

Presence of intermittent dry cough since 3 yrs.

Patient is unable to sleep towards his left side and couldn't flex his left leg more than 90 degrees while sleeping

Daily routine

Patient wakes around 6am in the morning,has breakfast and goes to work.He is a businessman who travels on bike a lot. He has been doing this for the past 12 years

Since 2 yrs there has been reduced travelling on bike due to pain.

Personal history

No similar complaints in the past. Not a known case of diabetes,hypertension,asthma.

Patient is c/c/c

Appetite-mixed

Diet-normal

Bowel and bladder movements- Normal micturition

Decreased bowel movement

Addictions- Stopped drinking 4 years ago

No smoking

Sleep-Adequate

General examination

Pallor: absent

Icterus:absent

Clubbing: absent

Cyanosis: absent

Lymphadenopathy: absent

Edema: absent

Vitals

Fever-afebrile

BP-130/80

HR-75

Respiratory rate-24 cpm

 Radial artery-75 BPM

 Dorsalis pedis artery-65

Treatment history

Patient was treated 3 yrs back but there was no reduction of pain upon medication.

Investigation

   Reflexes   

                Left.     Right  

   Biceps ++.          ++

   Triceps. ++.        ++

   Knees.     ++        ++

   Ankle. ++.          ++

  Gait- Normal

  Skin -Normal

Provisional diagnosis

Lumbar Spondylosis