outpatient dept- not so severe

complaint of lower back pain - between lower arch of ribs to buttocks. dull ache/ stabbing or shooting. pxn hard to move or stan up straight

1. muscle strain

2. osteoporosis

3. degenerative disease

4. TB spine

5. slip disc

6. spondyelolisthesis

7. kidney stone

8. back injury/trauma

9. ankylosing spondylitis

10. tumor/spinal malignancy

further questioning

1. S- pain localised or generalised

   O- when pain started

   C- throbbing or stabbing

   R- radiation, spread to other part or not (no radiation)

   A- is there any other symptom (weight loss/apetite?) (weight gain)

   T- how long/ time of the day

   E- exacerbating & relieving factor (exacerbated with exertion)

   S- 1-10

2. PMH- underlying disease(HIV/DM, scoliosis, or disease related to abdominal muscle, autoimmune disease-infxn/corticosteroid), history of trauma/surgery/hospitalization, previous TB disease/contact?

3. FH - familial disease (cancer/DM/TB/AIDS) member with similar pain?

4. SH - drug abuse/alcohol/smoking/lifestyle-active or not

• past three weeks, the pain became worse than usual: indicate significant change in underlying condition, compression of vertebra, progression of osteoporosis

• pain was fairly localised without radiation (confine to specific area )

• exacerbated with exertion (common feature of MSK condition).

• not experience any tingling, numbness or weakness (did not involve CNS)

• weight gain up to 80 kg (increased 5 kg over one year) and he felt he might be "shrinking : sedentary lifestyle, shrink dt bone density reduced, e.g: osteoporosis.

• Past medical history was unremarkable. The patient had no history of undergoing surgery or having trauma in the past: pain less likely dt complication of surgery or injury e.g at spinal cord injury

• Family history. no family history of chronic diseases or malignancies: pt has low risk of getting inherited dz e.g: ankylosing spondylitis, slip disc

• Medications and allergies. no history of being treated with systemic glucocorticoids (Tx for inflammatory autoimmune, pt don't have any autoimmune before, SE: can cause osteoporosis)or receiving androgen-deprivation therapy. (for prostate ca). both drugs can cause increase in weight.

• There were no known allergies revealed.

• smoker with a 45 pack-year history : risk factor of osteoporosis. disrupt hormone in body estrogen & testosterone. can make bone more porous

• a history of moderate alcohol consumption : can cause kidney dz, can't regulate Calcium absorption. kidney can indirectly cause activation of vitD. alcohol can cause hypercortisolism.

further investigation:

1. vital signs (Temp, HR, BP, RR)

2. PE: alertness consciousness, posture & spinal alignment, scar, skin changes, abd muscle swell, palpate spine at lumbar region pelvic bone at sacral region, to detect tenderness or mass.

   examine power, sensation

occiput wall distance - test for severity of the curvature & degree of head posture

rib-pelvis distance - vertical distance of lower border of rib cage & iliac crest of pelvis

fingerbreadths - use finger to measure rib-pelvis distance

Further ix:

1. Serum calcium, vit D, Phosphate

2. X-ray

3. FBC - check TB spine? anemia?

Dual X-ray absorptiometry (DXA)- imaging test to measure bone mineral density,evaluate risk for fracture and osteoporosis

T-score - assessing bone desnity.-1 - 1 - normal

Lumbar support back brace - provide support and stability for back

Rft normal-kidney functioning well

low bone desnity at femoral neck with 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- triangular wedge appearance indicates vertebrae have collpased or merged

diagnosed with osteoporosis complicated with a vertebral compression fracture - 1 or 2 is collapsed d/t weakening of the bones

Therapy with a bisphosphonate (alendronate) was started along with calcium and vitamin D supplementation-cal provide building block for bone formation & vit d promotes bone strength

Lumbar support back brace for 12 weeks was given to help alleviate lower back pain and stabilise the injury -reduce movement and pain because pain is exacerbated by movement

prescribed non-steroidal anti-inflammatory drugs for the pain- reduce the pain

Cessation of alcohol consumption- damage kidney ,reduce exacerbation of pain

physiotherapy programme with manual techniques, clinician-led exercises, and home exercises were recommended- improve mobility and strength of the bone

follow-up appointment made after three months, serial spinal radiographs showed

progressive vertebrae union.- rpocess of two or more spine to be fused,exeprienced improvement,positive sign of healing.