41 yr old male complaints of left leg pain.

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Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

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

History of presenting illness

Patient was apparently asymptomatic 4yrs ago but developed joint pain starting from left pubic area which was radiating towards the whole left leg(from hip joint to ankle joint) upon movement and resting for period of 10-20 mins associated with  fever of temp 100-101°F which subsided upon resting.
He also experienced numbness in the left leg for a period of 20-30 mins when the pain is more and loss of touch sensation was seen.
He also says that pain in left shoulder was present 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 and complete his daily routines,completes his tiffin and goes to work.He is a businessperson by occupation and involves travelling on bike more frequently,he has been doing work since 12yrs.And the work includes sleepless nights also.
Since 2 yrs there has been reduced work and reduced travelling on bike due to pain.

Personal history
He has no similar complaints in the past. Not a known case of  diabetes,hypertension,asthama.
Patient is c/c/c
Appetite-mixed
Diet-normal
Bowel and bladder-normal voidation of urine
    Decreased bowel movement
Addictions- was an ocassional alcohol consumer stopped since 4 yrs after onset of pain
No smoking
Sleep-Adequate 4-5hrs normally 
        Since 4 yrs 5-6 yrs.

General examination

Pallor: absent
Icterus:absent
Clubbing: absent
Cyanosis: absent
Lymphadenopathy: absent
Edema: absent

Vitals
Fever-afebrile on the time of examination
BP-130/80
HR-75
Respiratory rate-24 cpm
Puls rate
  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.

Anemia findings-
icterus findings-

Clubbing findings-




Investigation
Gait-

                                Left.            Right. 
   Reflexes     
      Biceps               ++.                ++
       Triceps.            ++.                ++
      Knees.               ++.                ++
      Ankle.                ++.                ++

  Gait- Normal
  Skin -Normal

Provisional diagnosis
Lumbar Spondylosis

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