18 yr old female with ? proximal myopathy under evaluation

Patient came with c/o low backache radiating to both lower limbs since 1 month and bilateral knee joint pain since 1 month
HOPI : 
Patient was apparently asymptomatic one month back later she developed fever which is low grade not associated with chills and rigor , relieved on medication. Then  one week after accompanied by low backache which is gradual in onset followed by swelling of both lower limbs and after 2 days pain in both lower limbs , which is continuous in nature , relieving on medication and recurring on stopping medication. Generalised body pains and weakness also present since one month, difficulty in getting up from sitting and squatting position
C/o hair fall since 1 year
Ankle edema present in b/l lower limbs
PAST HISTORY:
No similar complaints in the past
Not a k/c/o dm , htn , thyroid disorders
No cold or heat intolerance

PERSONAL HISTORY:
Loss of appetite , no burning micturition , yellowish discoloration of urine is present

GENERAL EXAMINATION: 
Pallor - present , no icterus , cyanosis, clubbing , lymphadenopathy , edema present (non pitting b/l lower limbs)
Temp : 98.6 f
Pr :86 bpm
Bp:110/70 mmhg
Spo2: 98%
SYSTEMIC EXAMINATION :
RS : Bilateral air entry present , normal vesicular breath sounds , 
 
P/A : soft , non tender , bowel sounds present
 
CVS : S1 S2 present , no murmurs 

CNS : 
No abnormalities detected
Right                Left

Bulk :                
      Upper limb         Normal            Normal   .         
    Lower limb .        Normal.           Normal

Tone: 
      Upper limb:.     Normal.         Normal
      Lower limb:.     Normal.        Normal 

Power:
      Upper limb:.     4/5.               4/5
      Lower limb:.     4/5.                4/5
 following commands
 
Motor system 
Reflexes:  
  
   Deep tendon reflexes: 
      Biceps:.            3+                 3+
      Triceps:.           3+                 3+
      Supinator:.       3+                3+
      Knee:.                Areflexia
      Ankle:.                Delayed ankle reflex on rt side

Reflexes : delayed ankle reflex present


Gluteus muscle testing :

Cerebral signs :
Finger nose test , knee heel test - normal
Rombergs - swaying to back

MUSCULOSKELETAL SYSTEM : 
Pain noted in low back and knee and proximal muscles of thigh 

Gowers sign and gait :


INVESTIGATIONS:
Cbp
Cue
esr
Crp

Serum electrolytes


Rx : 
1 TAB DOLO 650 MG PO/TID
2 INJ  OPTINEURON 1 AMP IN 100 ML NS/IV/OD
3 TEMP , BP , PR MONITORING

SOAP NOTES Day 1 :

S- low backache radiating to both lower limbs

O- Patient is conscious, coherent, co-operative

 pallor present ,edema present b/l lower limbs, No cyanosis, clubbing, lymphadenopathy, icterus
VITALS :
Temperature - 99.4F
Pulse rate - 84BPM, REGULAR, NORMAL VOLUME
BP : 110/70 mmhg

SYSTEMIC/ EXAMINATION - 
P/A : soft , non tender

CVS : S1 S2 heard , no murmurs
RS : BAE +, NVBS
CNS : No abnormalities detected
Delayed ankle reflex is present 
MUSCULOSKELETAL SYSTEM : Pain noted in low back and knee and proximal muscles of thigh 
Gowers sign present

A - PROXIMAL MYOPATHY UNDER EVALUATION

P -1 TAB DOLO 650 MG PO/TID
2 INJ OPTINEURON 1 AMP IN 100 ML NS/IV/OD
3 TEMP , BP , PR MONITORING

SOAP NOTES DAY 2
S- low backache radiating to both lower limbs

O- Patient is conscious, coherent, co-operative

 pallor present ,edema present b/l lower limbs, No cyanosis, clubbing, lymphadenopathy, icterus
VITALS :
Temperature - 98.1F
Pulse rate - 84BPM, REGULAR, NORMAL VOLUME
BP : 110/70 mmhg

SYSTEMIC/ EXAMINATION - 
P/A : soft , non tender

CVS : S1 S2 heard , no murmurs
RS : BAE +, NVBS
CNS : No abnormalities detected
Delayed ankle reflex is present 
MUSCULOSKELETAL SYSTEM : Pain noted in low back and knee and proximal muscles of thigh 
Gowers sign present

A - PROXIMAL MYOPATHY UNDER EVALUATION

P -1 TAB DOLO 650 MG PO/TID
2 INJ OPTINEURON 1 AMP IN 100 ML NS/IV/OD
3 TEMP , BP , PR MONITORING




SOAP NOTES DAY 3
S- low backache radiating to both lower limbs

O- Patient is conscious, coherent, co-operative

 pallor present ,edema present b/l lower limbs, No cyanosis, clubbing, lymphadenopathy, icterus
VITALS :
Temperature - 98.2F
Pulse rate - 82BPM, REGULAR, NORMAL VOLUME
BP : 110/80 mmhg

SYSTEMIC/ EXAMINATION - 
P/A : soft , non tender

CVS : S1 S2 heard , no murmurs
RS : BAE +, NVBS
CNS : No abnormalities detected
Delayed ankle reflex is present 
MUSCULOSKELETAL SYSTEM : Pain noted in low back and knee and proximal muscles of thigh 
Gowers sign present

A - PROXIMAL MYOPATHY UNDER EVALUATION

P -1 TAB DOLO 650 MG PO/TID
2 INJ OPTINEURON 1 AMP IN 100 ML NS/IV/OD
3 TAB HIFENAC MR PO/BD
4 TEMP , BP , PR MONITORING

Comments

Post a Comment

Popular posts from this blog

pt with Ataxia secondary to ? alcoholic neuropathy

Image
A30 yr old male came with c/o weakness of both lower limbs since yesterday (4/4/22) Difficulty in walking since yesterday (4/4/22) HOPI :  Pt was apparently normal since 2 days back then he developed generalised weakness and difficulty in walking associated with weakness of both lower limbs PAST HISTORY :  Not a k/c/o htn , dm , epilepsy , asthma , tb PERSONAL HISTORY :  Chronic alcoholic , daily 360 ml of whisky per day , last binge 1 day back ( on 3/4/22) Bowel and bladder are regular No significant family history GENERAL EXAMINATION :  No pallor , icterus, cyanosis ,clubbing, lymphadenopathy, koilonychia Temp : afebrile Pr :86 bpm Bp:110/60 mmhg Spo2: 98% SYSTEMIC EXAMINATION : RS : Bilateral air entry present , normal vesicular breath sounds ,    P/A : soft , non tender , bowel sounds present   CVS : S1 S2 present , no murmurs  CNS : No abnormalities detected INVESTIGATIONS :  Hemogram Rft Lft C x ray ecg APRAXIA CHARTING
Read more

70 yr old female with aspiration pneumonia (rt lung consolidation) , acute cva 20 days ago

Image
70 year female brought to casualty in a •unresponsive state which is since one day •no verbal response since 1 day  •fever since one day  5 years ago diagnosed with hypertension using Tab.Amlong 5mg OD 20 days ago complaints of giddiness followed by fall in bathroom injury to right   lower limb assc with displaced IT fracture Admitted outside hospital diagnosed with moderate size acute non hemorrhagic infract  in left caudate,lentiform nucleus ,chronic infarct left cerebellar hemisphere Age related atrophy with small v/s ischemic changes -FAZEKAS GRADE 3 On USG ABDOMEN AND PELVIS - NORMAL STUDY CAROTID AND VERTEBRAL DOPPLER STUDY — RIGHT CAROTID PARTIALLY CAROTID SMALL PLAQUE (7.5X2 MM)AT BIFURCATION CAUSING NO STENOSIS IMPRESSION —BILATERAL MILD ATHEROSCLEROTIC CHANGES .NO E/O THROMBOSIS. NO E/O SIGNIFICANT STENOSIS. PATIENT CAME TO CASUALTY IN UNRESPONSIVE STAGE WITH NO VERBAL RESPONSE ASSOCIATED WITH FEVER SINCE 1 DAY  NOT A K/C/O HTN , DM, ASTHMA GENERAL EXAMINATION:  No Pallor  ,
Read more

60 yr old male with CRF , ? FLASH PULMONARY EDEMA SECONDARY TO CRF , ? CARDIOGENIC PULMONARY EDEMA SECONDARY TO HF WITH REF , UNCONTROLLED HTN , ? KOCHS

Image
60 year old male patient brought to casualty with c/o sob ( grade 4 ) since 5 days , decreased urine output , vomitings , pedal edema since 1 day HOPI :  Pt was apparently asymptomatic 5 days back then he developed sob which is gradual in onset and progressive which was associated with vomitings (watery), also developed pedal edema non pitting type and also presented with decreased urine output PAST HISTORY:  6 months back pt complained of giddiness and went for hospital dont know the reason but they have been tested for sputum for tb which turned out to be negative 3 months back in feb 2022 pt developed acute sob grade 4 associated with sweating , at this time the pt diagnosed with heart failure with decreased ejection fraction and  Renal failure ,  serum creatinine 2 to 3 , heart failure is acute on chronic  , at that time trop i is normal 0.1 ng/ml and Nt pro BNP test was > 3,500 pg/ml (normal = 450 pg/ml) , htn was also diagnosed , ct lung was done  In MARCH he compl
Read more