37 yr old male with low back ache

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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.

Case taken By R.Akhil Chowdary, Ch.Asritha reddy 

TELEPHONIC HISTORY TAKING 

A 37 yr old male resident of coochbehar  of West Bengal came with 

Cheif complaints: 

Low back ache since july 2022    

HOPI:

Patient is a resident of Coochbehar of westbengal started working as employee in private company, patient was apparently asymptomatic 10 months back then he developed low back ache which was insidious in onset ,gradually progressive, non radiating type ,continuous ,has no diurnal variations,it aggravates on sitting for longer duration and also associated with tingling sensation so he unable to sit for longer duration, and has no relieving factors. He stopped lifting heavy weights because of back pain.

Patient had used antacids ? to relieve the pain from nearby pharmacy which was of no use , so he consulted a doctor in a local hospital in aug 2022 where he was investigated (mri and x ray was done)and was diagnosed as lumbar spondylosis and was given 6 injections Rejunuron on alt days followed by 4 injections of decadurabolin 50mg for every 3 weeks but there was no relief for the patient and was also diagnosed with hypertension  and using tab .clinidipine 10mg since then . 

Patient started having pain and tingling sensation in left foot since 4 months insidious in onset ,intermittent in nature so he again consulted the doctor was given medication ( tab.nervite plus for 3 weeks ) and advised for surgery if the pain has not resolved further.

Past history: 

k/c/o Hypertension since 9 months on medication (tab.clinidipine 10 mg).

k/c/o Lumbar spondylosis since 9 months.

 Not a k/c/o dm,tb,epilepsy,asthma,thyroid disorders,no history of trauma.No history of surgeries.

Family history:

 No significant family history 

Personal history: 

Patient completed his education until 7th standard, he got married in 2011 have two kids ,1st child is female 11 yrs old and 2nd child boy 11 months. He is an employee in private company since 2008 . He regularly starts for work at 10 am and mostly travel on bike for the work related to company until 2pm and then he takes his lunch and sits in work place from 3 pm to 10 pm . Later he goes home have dinner and sleep by 12 am.  

Patient stopped working since feb 2023 because of sever backpain and also stopped riding bike 

Diet: Mixed 

Appetite: Normal 

Sleep: adequate 

Bowel and bladder movements: Regular 

Addictions: Had a habit of taking alcohol occasionally since 2015 but stopped consuming completely since 1 and half year. 

No allergic history.

Treatment history: 

Tab.clinidipine 10mg daily 

Inj Rejunuron forte 

Inj Decadurabolin 50mg 

Tab Nervite plus