outpatient department- not in ward/ just clinic

64-year old retired male

presented to the outpatient department

lower back pain

64-year old retired male- senior citizen, compromised immune system, easy tired, sedentary lifestyle, suscebtible with cormobidities, muscle degeneration,atrophy, etc. Past occupational related

presented to the outpatient department- not severe enough

lower back pain - age related, fragile, due to body posture, injury, past job, common for elder

been experiencing aching pain in the lower lumbar area

for the last few months

during the past three weeks, the pain became worse

fairly localised without radiation, exacerbated with exertion

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”

PMH, FH, medication and allergies : unremarkable

Social: smoker with a 45 pack-year history. The patient had a history of moderate alcohol consumption.

been experiencing aching pain in the lower lumbar area for the last few months

• chronic condition, pain become unbearable - change in lifestyle/trauma

• may be degenerative disease

during the past three weeks, the pain became worse

• progressive pain due to activity that damage spine and vertebra

fairly localized without radiation, exacerbated with exertion

• pain is localized with no radiation, less likely to be systemic, less likely to be prostate cancer.

• when doing activity - back pain become worse

did not experience any tingling, numbness or weakness.

• normal neurologic function - no compression, demyelinating

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”

• decrease in posture - the feeling of shrinking - hunching

• not likely malignancy

• weight gain can exacerbate mechanical strain of lower back

PMH, FH, medication and allergies : unremarkable

• rule out trauma

• less likely heart disease, HTN, DM, cancer

Social: smoker with a 45 pack-year history. The patient had a history of moderate alcohol consumption.

• risk factor causing immunodeficiency

• risk factor for bone related diseases

fingerbreadths - width of distal of two fingers

kyphosis - exaggerated forward curvature of thoracic spine resulting in hunched or rounded back (excessive forward rounding of the upper back)

rib-pelvic distance - anatomical distance between lower rib and top of pelvis (used to assess postural changes that may indicate vertebral fracture)

occiput-wall distance - test to measure distance between head and wall (for hunchback)

lumbar radiculopathy - condition where there is compression, inflammation or irritation of one or more lumbar nerve roots in lower back

normal temp, HR, BP

borderline high RR

alert and well-oriented

BMI is 24.7 kg/m2: normal

prominent kyphosis of thoracic spine and occiput-wall distance more than 5cm

rib-pelvis distance less than two fingerbreadths

no gait

localised tenderness to palpation in lower lumbar area

no lumbar radiculopathy or nerve damage

5.5cm shorter in height than 5 years ago

no regional lymphadenopathy

others normal

normal temp, HR, BP

• no systemic symptoms

• no inflammation

• no shock or stress

borderline high RR

• due to pain

• due to affected airways caused by hunching

• harder to breathe

alert and well-oriented

• no neurological deficit

BMI is 24.7 kg/m2

• normal

prominent kyphosis of thoracic spine and occiput-wall distance more than 5cm

• hunchback

• can cause compression fractures in cases of osteoporosis

rib-pelvis distance less than two fingerbreadths

• positive finding of vertebral deformities

• normal range: 2-3 fingerbreadths

no gait

• normal walking posture

• no joint pain or nerve damage

• no lower limb problem (mainly spine related)

localised tenderness to palpation in lower lumbar area

• underlying issue related to spine, muscle or surrounding structures

no lumbar radiculopathy or nerve damage

• no compression of spinal nerves

5.5cm shorter in height than 5 years ago

• due to kyphosis

• may be other components or structures that collapsed causing shortening

• bone becomes brittle and weak leading to height reduction

no regional lymphadenopathy

• no abnormal lymph node enlargement

• no systemically involved diseases or inflammation

• no infection, no malignancy

others normal

• no systemically involved diseases or inflammation

FBC

XRay

serum plasma: calcium, vitamin D, PTH hormone, calcitonin, CRP, ESR, renal function test