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I would like to thank Dr. Rishik Sir for providing me the case details.
Case History :
A 30 year old female presented to the OPD on 24th October, 2021 with
Chief Complaints :
Lower backache on both sides since 2 years
Knee pain on both sides since 2 years
History of Present Illness :
Patient was apparently asymptomatic 2 years back when she developed pain in both sides of the lower back and bilateral knee joints. The pain was insidious in onset, gradual in progression which was dragging type of pain. Pain was more in the morning and was associated with morning stiffness and weakness of both lower limbs. It was aggravated on walking and relieved on taking rest or medication.
No history of fever, cough, dyspnea, night sweats or night cries.
No history of oliguria or burning micturition.
No history of swelling, enlarged abdomen, itchy skin or abdominal swelling.
No history of loss of weight or loss of appetite.
Past History :
Patient had similar complaints in past and diagnosed with hyperkalemia and was given Potklor syrup.
The patient is not a known case of Hypertension, Diabetes mellitus, Thyroid disorder, Epilepsy, Tuberculosis, Coronary Artery Disease, Asthma.
Personal History :
Diet : Mixed
Appetite : Normal
Bowel and Bladder movements : Regular
Sleep : Adequate
Addictions : Toddy occasionally
Menstrual History :
Her menstrual cycles were regular which lasted for 3 days in a 28 days cycle. It was not associated with abdominal pain or foul smell or heavy bleeding or clots.
Obstetric History :
Obstetric Formula : G2P2L2
Age at marriage : 14 years
1st Pregnancy : At an age of 15 years
LSCS as the patient was weak.
Male child, healthy and no delayed milestones.
2nd Pregnancy : 17 years
LSCS due to LSCS at 1st pregnancy.
Female child, health and no delayed milestones.
Family History :
Father died of a heart attack at 30 years of age.
General Examination :
The examination was done after obtaining informed consent in a well lit room.
Patient was conscious, coherent, co-operative and well oriented to time, place and person.
She is poorly built and poorly nourished.
There was no pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema.
Oral cavity examination : Bifid uvula, high arched palate
Tremors : Present
Posture : Fixed Flexion Deformity present
Vitals :
Temperature : Afebrile
Pulse Rate : 96 bpm
Respiratory Rate : 16 cpm
Blood Pressure : 100/60 mm Hg
Systemic Examination :
Respiratory system : BAE present
Cardiovascular System : S1,S2 heard, no murmers
Per Abdomen : Soft, non-tender
Central Nervous System :
• Higher Mental Functions : Intact
• Cranial Nerves: NAD
• Motor system:
Right side Left side
Bulk : U/L - Arm 16 cms 16 cms
- Forearm 15 cms 15 cms
L/L - Thigh 23.5 cms 23.0 cms
- Leg 18.5 cms 18 cms
Tone : U/L Hypertonia Hypertonia
L/L Hypertonia Hypertonia
Power :
Shoulder
Deltoid 4+/5 4+/5
Supraspinatus 4+/5 4+/5
Infraspinatus 4+/5 4+/5
Rhomboids 4+/5 4+/5
Serratus Anterior 4+/5 4+/5
Pectoralis major 4+/5 4+/5
Latissimus dorsi 4+/5 4+/5
Elbow
Biceps 4+/5 4+/5
Triceps 4+/5 4+/5
Brachioradialis 4+/5 4+/5
Forearm and wrist
ECR 4+/5 4+/5
ECU 4+/5 4+/5
ED 4+/5 4+/5
FCR 4+/5 4+/5
FCU 4+/5 4+/5
EPB 4+/5 4+/5
EPL 4+/5 4+/5
FDP 4+/5 4+/5
Abductor pollicis 4+/5 4+/5
Adductor pollicis 4+/5 4+/5
Opponens pollicis 4+/5 4+/5
Lumbricals 4+/5 4+/5
Hip girdle
Iliopsoas 4+/5 4+/5
Adductor femoris 4+/5 4+/5
Gluteus medius 1/5 1/5
Gluteus maximus 1/5 1/5
Hamstrings 4+/5 4+/5
Quadriceps femoris 4+/5 4+/5
Tibialis Anterior 4+/5 4+/5
Tibialis posterior 4+/5 4+/5
Peritonei 4+/5 4+/5
Gastronemius 4+/5 4+/5
EDL 4+/5 4+/5
FHL 4+/5 4+/5
REFLEXES Right Left
Biceps +++ +++
Triceps +++ +++
Supinator +++ +++
Knee +++ +++
Ankle +++ +++
Plantar Mute Mute
• Sensory System:
All Sensations are Intact.
• Gait:
Provisional Diagnosis : Bilateral Osteoporosis
Investigations :
Hemogram :
Serum T3, T4, TSH :
ECG :
X- ray :
Vitamin D and Paratharmone levels :
Referrals :
TREATMENT:
@ 24/08/2021
1. INJ. OPTINEURONE 1AMP IN 100ml NS IV/OD
2. TAB. MVT PO/OD
3. TAB. PREGABALINE 75mg PO/ HS
@ 25/08/2021
1. INJ. OPTINEURONE 1AMP IN 100ml NS IV/OD
2. TAB. MVT PO/OD
3. TAB. PREGABALINE 75mg PO/ HS
4. BP/PR/TEMP/RR MONITORING 12th Hourly
@ 26/08/2021
1. TAB. MVT PO/OD
2. TAB. PANTOP 40mg OD
3. TAB. PREGABALINE 75mg PO/ HS
4. TAB. SHELCAL OD
5. BP/PR/TEMP/RR MONITORING 12th Hourly
@ 27/08/2021
1. TAB. MVT PO/OD
2. TAB. PANTOP 40mg OD
3. TAB. PREGABALINE 75mg PO/ HS
4. TAB. SHELCAL OD
5. CAP. VIT D3 60K IU OD/ ONCE WEEKLY
6. TAB. ULTRACET 1/2 TABLET QID
7. BP/PR/TEMP/RR MONITORING 12th Hourly
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