18YROLD MALE WITH B/L WEAKNESS AND EDEMA OF LL
ANKAM SATHYA KISHORE (07)
Following is the my analysis of the 18 year old male patient with bilateral weakness and edema of lower limbs:
You can find the entire real patient clinical problem in this link here made by our interns
https://hitesh116.blogspot.com/2020/05/12may-2020-elog-medicine-intern.html?m=1
https://srianugna.blogspot.com/2020/05/hello-everyone.html
Chief complaints:
*Weakness of both lower limbs since 20 days.
Weakness initially started in the proximal region 2 years back .
Onset: insidious in onset ,
Progression:progressed gradually to distal region
Associated features
-difficulty in wearing and holding chappals
-difficulty in combing hair , buttoning and unbuttoning shirt.
---B/L calf hypertrophy present
*Bilateral edema in lower limbs
PAST HISTORY:
NO C/O HTN,DM,CVA, EPILEPSY,CAD,TB,THYROID
PERSONAL HISTORY:
diet-mixed
appetite-normal
sleep-adequate
B&B-regular
FAMILY HISTORY:
not significant
-no known food or drug allergies
GENERAL EXAMINATION:
-patient was conscious, coherent and coperative
-moderately built and nourished.
-no signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema
VITALS:
*temperature-AFEBRILE
*pulse rate-92bpm
*respiratory rate-18 cycles/min
*BP-130/90mmhg
*SpO2-96%
*GRBS-142mg/dl
SYSTEMIC EXAMINATION:
I.CVS-
S1 S2 heard
no added murmurs
2.RESPIRATORY SYSTEM-
-normal vesicular breath sounds heard
-bilateral air entry present
3.PER ABDOMEN-
shape=scaphoid
umbilicus=central and normal in position
all quadrants moving equally on respiration
no tenderness
no organomegaly
bowel sounds-heard
no bruit heard
4.CNS-
patient is conscious, coherent, coperative
patient well oriented to time, place and person
higher mental functions= normal
Cranial nerves- intact
Motor system-
tone - normal
power - 4-/5 in both lower limbs
reflexes absent in both lower limbs
sensory system-normal
No meningeal signs
No cerebellar signs
Muscle biopsy should be done and examination of creatine kinase levels must be done.
Creatine levels -increased
Muscle biopsy report(quadriceps femoris)- suggesting no evidence of POLYMYOSIS and may be suggestive of dystrophy.
Other investigations:
1.CBP -normocytic normochromic with leucocytosis
2.serology
3.RFT-creatinine and uric acid levels are slightly elevated
4.ECG- normal
5.CUE- pus cells seen
are done and these reports are within normal range.
Provisional Diagnosis:
*Becker's muscular dystrophy:
-Here muscle wasting resembles Duchene's
-proximal muscle weakness of lower extremities occur first
-Onset 5-15 years of age
-Dystrophin muscle protein is absent
-Calf muscles shows hypertrophy due to accumulation of fat cells and necrotic tissue.
TREATMENT:
T Prednisolone 15mg po od
T Pantop 40mg bbf
T Met xl 12.5mg od
Cap Becosules od
T Chymerol forte od
T Taxim 200mg bd
T Vit c od
T Ultracet sos