GEN MED E-LOG CASE 2
A. Rishi koundinya
Rollno: 7
Date: August 30
30yr Old Female with Pain in B/L Lower limbs since 2 years. ? Osteomalacia
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CASE
A 30yr old female, Daily wage Labourer by occupation came to OPD with cheif complaints of
Pain 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.
Provisional Diagnosis:
SEVERE OSTEOPOROSIS
? OSTEOMALACIA
HEMOGRAM
@25/08/21
@26/08/2021
@27/08/2021
OMFS REFFERAL I/V/O OSTEOPOROSIS AND OSTEOMALACIA CHANGES IN XRAY
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