29 year old male with lower back pain since 3 months

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A 29 year old came to opd with the 
- c/o back pain since 3 months
- c/o lower limb pain since 3 months

HOPI :
Patient was apparently asymptomatic 3 months back then he developed lower back pain radiating to left lower limb since 3 months
No h/o trauma
No h/o fever , burning micturition
No h/o B&b incontinence

Past history
N/k/c/o DM,HTN, EPILEPSY, ASTHMA 

Family history
Similar complaints in the mother 

Personal history
Diet - mixed 
Sleep - adequate
Appetite- normal
Bowel & bladder- regular
No addictions

General examination
Patient is c/c/c
Oriented to time ,place , person
No pallor, icterus , cyanosis, clubbing, koilonychia , lymphadenopathy,edema

Vitals 
BP- 110/80 mmHg
PR-72 Bpm
RR -16cpm
Temp-98.6F

Systemic examination
CVS - S1S2+,NO Murmurs
RS -BAE+,NVBS HEARD
P/A-SOFT ,NON TENDER,NO ORGANOMEGALY
CNS Examination
Tenderness+
No spasm
ROM full @ LS spine
Decreased sensation over L4,L5,S1
            Right             Left
EHL       5/5             4/5

FHL      5/5            4/5

Plantar   5/5          4/5
flexion

Dorsi 
flexion.     5/5         4/5

Knee 
flexion &.     5/5            4/5
Extension   
 
Hip flexion  5/5         5/5


Investigations 

Hemogram
CUE
USG
ECG
MRI

ORTHO REFERRAL
Adviced conservative treatment with
1) T. PAN 40 MG PO OD
2)T. ETOVA ER 400MG PO BD
2) T. TRIGABANTIN 100 MG PO OD

DIAGNOSIS
SPONDYLOARTHROPATHY
1)L3/4, L4/5, disc bulge, Compressing the cauda equina causing narrowing of lateral
recesses bilaterally.
(2) Bilateral mild sacro-ilitis. 
(3) Bilateral sacralisation of L5.

TREATMENT
DAY 1
1) T .ULTRACET 1/2 QID
2)T. PAN 40 MG PO OD
DAY 2
1) T. PAN 40 MG PO OD
2)T. ETOVA ER 400MG PO BD
2) T. TRIGABANTIN 100 MG PO OD
DAY 3
1) T. PAN 40 MG PO OD
2)T. ETOVA ER 400MG PO BD
2) T. TRIGABANTIN 100 MG PO OD

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