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
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