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