GM Elog Case-7
RISHIK
R NO 37
A 30yr Old Female with ? Osteomalacia
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I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan
CASE
A 30yr old female, Daily wage Labourer by occupation came to OPD with cheif complaints ofPain in B/L Lower limbs since 2 years.
Patient was apparently asymptomatic 2 yrs back after which she developed lowback ache initially which is Insidious in onset and gradually Progressive. Over the period of this 2 years it progressed and involved Both the lower limbs to such an extent that she stopped her daily work and needed an aid for walking since 1 year.
Pain was Dragging type and aggrevated during work and relieved with rest and medication.
Patient gives history of NSAID use on & off at the times of pain in the past 2 years.
No H/O radiation
No H/O associated Tingling & Numbness in lower limbs
(H/O Tingling in UL occasionally)
She is not a k/c/o DM, HTN, Asthma, Epilepsy, TB, Thyroid, CAD, CVD
H/O Multiple Hospital visits where she was told to have Hypokalemia and adviced POTCLOR Syrup for 6 months but she used ot only for 2 months.
She underwent 2 LSCS' and Tubectomy in the past
Her Menses are Regular and bleeding was normal
Her Sleep was adequate, Appetite Normal, Diet is Mixed, B&B are regular.
Patient gives a H/O Unintentional Weight loss (?Kgs)
 |
| Summary/Timeline of Events |
ON EXAMINATION:
Patient was Conscious, Coherent, Co-operative,
Well Oriented to Time, Place, Person
Thin Built and looks Malnourished
BP: 100/80 mmHg
PR: 133 bpm
Temperature: Afebrile
Mild Pallor Present
No Signs of Icterus, Clubbing, Cyanosis, Koilonychia, Generalized Lymphedenolathy and Edema
Slurring of Speech present (seems to present since birth)
Oral Cavity shows Bifid Uvula, ? High arched Palate.
Tremors Present
Posture: Fixed Flexion Deformity Present
CVS: S1,S2 Present
RS: BAE Present, NVBS
PA: Soft, Non tender
CNS EXAMINATION
• HMF: Intact
• Cranial Nerves: NAD
• Motor system:
Rt Lt
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
Infra spinatus 4+/5 4+/5
Rhomboides 4+/5 4+/5
S. Anterior 4+/5 4+/5
P.major 4+/5 4+/5
Latismus 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
Tib. Anterior 4+/5 4+/5
Tib.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:
SEVERE OSTEOPOROSIS
? OSTEOMALACIA
Investigations
@24/08/2021
 |
| HEMOGRAM |
@25/08/2021
 |
| Serum Electrolytes @ 11:25 PM |
 |
| Serum Electrolytes @ 10:30 AM |
@26/08/2021
@27/08/2021
REFFERALS:
 |
| ORTHOPEDICS REFFERAL I/V/O OSTEOPOROSIS N OSTEOMALACIA CHANGES IN XRAY |
 |
| OMFS REFFERAL I/V/O OSTEOPOROSIS AND OSTEOMALACIA CHANGES IN XRAY |
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
@ 28/08/2021
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
@ 29/08/2021
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
@ 30/08/2021
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
Patient was Discharged on 30/08/2021 as they weren't willing to go for further follow-up & Investigations.
Investigations adviced for the patient at the time of discharge for further follow-up
On 30/08/2021
Patient used the prescribed medication for a period of 1 month and underwent following investigations
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