A 50 year old male

 This is a case of a 50 year old male who is a farmer by occupation used to work for 4-5 hours daily and got involved in heavy work like lifting heavy objects for 6 months after which he was asymptomatic for 2 months and later developed pain in the left hip and left leg region since 4 months pain is progressive burning type of pain radiating from hip region to leg which aggravates on walking for short distance like 100 metres after which he rests for 10 mins by standing in flexion position and the pain is relieved on posturing like knee elbow position and bending position and some injections by which he got relief for 9 days.

No difficulty in getting up from squatting position,no difficulty in rolling on bed,no sensory disturbance,no bowel and bladder involvement

PAST HISTORY  : history of fall from a tree height about 10 feet 15 years ago.

No h/o HTN ,DM , EPILEPSY , CVA , CAD , TB

FAMILY HISTORY : NAD

PERSONAL HISTORY : 

Diet - vegeterian

Appetite - normal

Bowel & Bladder - Regular

Sleep - Adequate

Addictions - no addictions

GENERAL EXAMINATION :

No Pallor , Icterus , Cyanosis , Clubbing , Lymphadenopathy

VITALS :

PR - 80 bpm

BP - 110/80 mm hg

RR - 17 cpm

SYSTEMIC EXAMINATION :

 Liver and spleen not palpable

CNS Examination :

Mini mental state examination : 25/25

Higher mental function : normal

Speech : normal

Spine : no deformities and tenderness

Cranial nerve : intact

Tone : upper limb right and left normal,lower limb right and left normal

Power:.             Right    left

U/L : shoulder - 5/5,5/5

Abduction and adduction - 5/5,5/5

Flexion and extension - 5/5,5/5

Elbow : flexion and extension : 5/5,5/5

Pronation and supination - 5/5,5/5

Hip : flexion -4/5 , +4/5 extension 5/5,5/5

Adbuction and adduction 5/5,5/5

Knee: flexion 5/5,5/5 extension  4+/5,5/5

Ankle : dorsiflexion  - 4/5,5/5

Plantar flexion  5/5 ,5/5

EHL -4/5,+4/5

Fine touch : 

Upper limb - normal(right),normal(left)

Lower limb -100%(right) , 100%(left)

Pain : 

Upper limb - normal (right), normal (left)

Lower limb - normal (right), normal(left)

Temperature:

Upper limb - normal(right),normal(left)

Lower limb- normal (right),normal(left)

Vibration:

Upper limb - normal (right),normal (left)

Lower limb - normal (right),normal(left)

Propioception : normal

Deep tendon reflexes : 

             Rt.       Lt

Biceps- +2.     +3

Triceps- +2.     +3

Brachioradialis- +2.      +3

Patellar- F.        F

Ankle - +2.        +3

Specific tests for sacroiliac joints :

Fabers test positive on left side 

Gaeslen's test negative

Sacral thrust positive on left side

 

Investigations :

Ecg:

X ray :

Mri:

Provisional Diagnosis:

? Left sacroileitis,L4 L5 disc prolapse