41 yr old male complaints of left leg pain.

 

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 



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. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.”


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 in  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

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.


Past history 

Not a known case of diabetes,hypertension,asthama.

Personal history 

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

Patient - c/c/c

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

Pulse 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.


icterus findings


Anemia findings-




Clubbing finding








Investigation

Gait- normal 



                                Left. Right. 

   Reflexes     

      Biceps ++. ++

       Triceps. ++. ++

      Knees. ++. ++

      Ankle. ++. ++


  Gait- Normal

  Skin -Normal


Differential diagnosis

Lumbar spondylosis , sacroilitis. 


Provisional diagnosis 

Sacroilitis.

Treatment 

Indomethacin  75 mg ( PO/OD) 

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