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64-year old retired male

presented to the outpatient department

a complaint of lower back pain

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64-year old retired male

-old age, susceptible for any muscle/bone issues

-inactive,lack of muscle usage-weakness muscle

-male=more susceptible to some ds

-have tendencies to have joint pain, any medical condition, weak immune system, immunocompromised

-maybe less calcium taken from dietary

presented to the outpatient department

-not admitted ,claim for tx

a complaint of lower back pain

-need to know specific location, maybe trauma ,bad posture lead to back pain

-obese? compressed lower back

-muscle strain due to heavy lifting

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muscle strain

osteoporosis

scoliosis

spinal malignancy

infection -osteomyelitis,osteoarthritis

neural defect

Paget ds

lumbar spondylosis

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S-more specific site ,left or right, level of the pain location

O-when did pain start?how long the pain last?

C-continuous/intermittent pain?,sharp/dull/throbbing pain?

R-does the pain radiate to others part?

A-headache,fever,nausea,vomiting,numbness,tingling ,significance loss of height, gait abnormality,

T-daytime/night time?

E-any specific position/work that worsening the pain, any medication /posture that relieve pain,

S-pain scale, how it affect daily activities

PMH

trauma

surgery/any hospitalisation?

medical intervention?

underlying medical condition

FH

similar symptoms

history of malignancy/metabolic syndrome

autoimmune ds?

DRUG H

medication?

NSAID?PPI?

SE medication

withdrawal of any medication

SH

smoking/alcohol/drug consumption

past occupation

dietary-caffein intake(increase cortisol)

daily activities

TRAVEL H

travel to any epidemic area

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experiencing aching pain in the lower lumbar area for the last few months, but during the past three weeks, the pain became worse than usual.

The pain was fairly localised without radiation, exacerbated with exertion.

The patient did not experience any tingling, numbness or weakness.

The patient also added that he had weight gain up to 80 kg (increased 5 kg over one year) and

he felt he might be "shrinking”.

Past medical history was unremarkable. The patient had no history of undergoing surgery or having trauma in the past.

Family history. He also disclosed that he had no family history of chronic diseases or malignancies.

Medications and allergies. The patient had no history of being treated with systemic glucocorticoids or receiving androgen-deprivation therapy.

There were no known allergies revealed.

Social history. The patient was a smoker with a 45 pack-year history.

The patient had a history of moderate alcohol consumption

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experiencing aching pain in the lower lumbar area for the last few months, but during the past three weeks, the pain became worse than usual.

-chronic condition, lower lumbar

The pain was fairly localised without radiation, exacerbated with exertion.

-not referred pain, more severe, lifting heavy items

The patient did not experience any tingling, numbness or weakness.

-no neuromuscular, nerve not affected

The patient also added that he had weight gain up to 80 kg (increased 5 kg over one year) he felt he might be "shrinking”.

-additional stress for pain, compression fracture or osteosprosis, bone resorption (age), aging (hormone imbalance)

Past medical history was unremarkable. The patient had no history of undergoing surgery or having trauma in the past.

-less likely surgical infection, not complication of surgery, rule out trauma

Family history. He also disclosed that he had no family history of chronic diseases or malignancies.

-less likely inherited condition

Medications and allergies. The patient had no history of being treated with systemic glucocorticoids or receiving androgen-deprivation therapy.

-not because of medication and side effects

There were no known allergies revealed.

-not due to allergy effect

Social history. The patient was a smoker with a 45 pack-year history.

-reduce blood supply -- lead to osteosporosis

The patient had a history of moderate alcohol consumption

-unlikely cause, maybe disturb calcium phosphate lead to bone fracture, inhibit osteoblast, dehydration,

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osteoporosis

scoliosis

infection -osteomyelitis,osteoarthritis

Paget ds

lumbar spondylosis

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vital sign : hr, temp, bp, rr

pe: inspection, palpate, auscultation, percussion

bmi

schober's test

rib pelvis distance test

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vital sign normal

alert and well-oriented.

The patient’s BMI was 24.7 kg/m2.

The physician noted prominent kyphosis of his thoracic spine

occiput-wall distance was more than 5 cm.

The rib-pelvis distance was

less than two fingerbreadths.

No gait changes were observed.

patient exhibited localised tenderness to palpation in the lower lumbar

area.

physical examination did not reveal any signs of lumbar

radiculopathy or nerve damage.

patient was approximately 5.5 cm shorter in

height than five years ago.

There was no evidence of regional lymphadenopathy.

The rest of the examination was normal.

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kyphosis - abnormalities to the spine that cause curvature to the spine

occiput-wall distance - test to diagnose kyphosis

lumbar

radiculopathy - damage to nerve root / inflammation which cause back pain in leg

gait - manner of walking

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vital sign normal

-no infection

alert and well-oriented.

-no neurological defect

The patient’s BMI was 24.7 kg/m2.

-overweight, bone damage and lower back pain

The physician noted prominent kyphosis of his thoracic spine

-indiactes obvious curvature of upper region thoracic spine. weakness of spinal bone, can lead to compression and cause fracture, osteoporosis or osteomyelitis

occiput-wall distance was more than 5 cm.

-indicates kyphosis

The rib-pelvis distance was

less than two fingerbreadths.

-compression on spine

No gait changes were observed.

normal walking pattern

patient exhibited localised tenderness to palpation in the lower lumbar

area.

-realted to specific area, lumbar

physical examination did not reveal any signs of lumbar

radiculopathy or nerve damage.

-no nerve irritation or compression at lumbar region

patient was approximately 5.5 cm shorter in

height than five years ago.

-due to kyphosis

There was no evidence of regional lymphadenopathy.

The rest of the examination was normal.

-no infection or malignancy

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osteoporosis

scoliosis

lumbar spondylosis

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blood test - ,vit c and d, calcium phosphate

liver function test - ALP

x-ray - to asses bone abnormalities

thyroid function test - to asses parathyroid function

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Prostatic Specific Antigen (PSA) - to diagnose prostate cancer, prone to males with osteoporosis, can mimic osteoporosis symptoms

Dual X-ray absorptiometry (DXA) - imaging technique used to measure bone mineral density

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blood test normal

RFT: within a reference range

Dual X-ray absorptiometry (DXA) test

results showed low bone density at the femoral neck

with a T-score of -1.9 (osteopenia) and a T score of -3.5 (osteoporosis) at L3-L5.

two vertebrae being

wedge-shaped meeting the criteria for vertebral compression fracture.

patient

was diagnosed with osteoporosis complicated with a vertebral compression fracture.

Therapy with a bisphosphonate (alendronate) was started along with calcium and vitamin D

supplementations.

Lumbar support back brace for 12 weeks was given to help alleviate lower back pain and stabilise the injury

was prescribed non-steroidal anti-inflammatory

drugs for the pain.

Cessation of alcohol consumption and physiotherapy programme with manual techniques, clinician-led exercises, and home exercises were recommended.

On a follow-up appointment made after three months

serial spinal radiographs showed

progressive vertebrae union.

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blood test normal

-no metabolic problem, no infection, vit d deficiency didn't cause osteoporosis, normal calcium and phosphate didn't cause bone resorption

RFT: within a reference range

- kidney normal

Dual X-ray absorptiometry (DXA) test

results showed low bone density at the femoral neck

with a T-score of -1.9 (osteopenia) and a T score of -3.5 (osteoporosis) at L3-L5.

- -1.0 to 1.0 is normal range, if -1.0 - 2.5 is osteopenia, -2.5 and below is osteoporosis

two vertebrae being

wedge-shaped meeting the criteria for vertebral compression fracture.

-spinal injury or curvature

patient

was diagnosed with osteoporosis complicated with a vertebral compression fracture.

- diagnosis

Therapy with a bisphosphonate (alendronate) was started along with calcium and vitamin D

supplementations.

-inhibt osteoclast activity

Lumbar support back brace for 12 weeks was given to help alleviate lower back pain and stabilise the injury

-facilitate movement, prevent further complications

was prescribed non-steroidal anti-inflammatory

drugs for the pain.

-N-saids : to reduce pain

Cessation of alcohol consumption and physiotherapy programme with manual techniques, clinician-led exercises, and home exercises were recommended.

-to alleviate symptoms, to increase bone remodelling

On a follow-up appointment made after three months

serial spinal radiographs showed progressive vertebrae union.

-good prognosis