30f with osteomalacia??

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A 30yr Old Female with ? Osteomalacia

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome


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 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)



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



HEMOGRAM























Serum Electrolytes @ 11:25 PM

Serum Electrolytes @ 10:30 AM



















REFFERALS:


ORTHOPEDICS REFFERAL I/V/O OSTEOPOROSIS N OSTEOMALACIA CHANGES IN XRAY



OMFS REFFERAL I/V/O OSTEOPOROSIS AND OSTEOMALACIA CHANGES IN XRAY

TREATMENT:

Day 1
1. INJ. OPTINEURONE 1AMP IN 100ml NS IV/OD
2. TAB. MVT PO/OD
3. TAB. PREGABALINE 75mg PO/ HS

Day 2
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
 
Day 3
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

Day 4
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

Day 5 
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

Day 6 
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

Day 7
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 

Investigations adviced for the patient at the time of discharge for further follow-up


On the day of discharge: 




Follow-up 

Patient used the prescribed medication for a period of 1 month and underwent following investigations 





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