37 F pain in left lower limb since 2 months

 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 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-centred 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.

Complaints:

37 years female came with chief complaints of

Pain of the left lower limb since 2 months


History of presenting illness:

Patient was apparently

asymptomatic 2years back, then

develored B/L joint pains (knee), Insidious in onset, gradually progressive

No aggrerating factors and relieved on medication.

History of distal muscle weakness , difficulty in mixing food, buttonning and unbuttoning of shirt.

H/O Proximal muscle weakness, difficulty in getting from squatting position.

 (diagnosed as dermatomyositis)

followed by 1 year back, cough with sputum, yellowish, non-foulsmelling non-blood tinged, moderate in amount, diagnosed as Pulmonary

Nocardiosis(cotrimoxazole)

Presently using:

T.Wysolone 20mg

T.Azathioprine 100mg

T.Naproxen 250mg

Now, since 2 months,

c/o Pain of the left lower limb., insidious in

Onset, gradually progressive, aggrevated by standing and walking, Not relieved with Medication(more since past 7 days),dragging type,

radiating down the leg upto ankle

 C/o difficulty in getting up from sitting position since 7 days

C/o tingling and numbness of both upper and lower limbs since 7 days

 polydypsia present,No polyuria, Polyphagia, Nocturia .

c/o Pedal edema since today afternoon, pitting type upto ankle

No c/o Fever, vomitings, decreased urine output, burning micturition,Chestpain,Palpitations

H/o diarrhea associated with pain abdomen 5 days back,watery stools 5-6 episodes per day,foul smelling,non blood stained


PAST HISTORY:

N/k/c/o HTN,DM,Thyroid disorders,Epilepsy 


PERSONAL HISTORY:

Diet-mixed 

Appetite-normal

Bowel and bladder-regular

Addictions-None


DAILY ROUTINE 

She daily wakes at 5 AM and takes bath and fresh up drinks tea at 7am and then she takes her breakfast  (idly/dosa) at 8am and takes her lunch at 1 pm which consisting of a vegetable curry and rice and after  she chit chat with her neighbors and lie down for some time and after that she watch TV and then eats her dinner at 8pm and goes to sleep at 9pm.


FAMILY HISTORY:

Insignificant


GENERAL EXAMINATION:

Patient is conscious coherent and cooperative 

No pallor ,icterus , clubbing,cyanosis,lymphadenopathy ,pedal edema

Vitals : 

BP- 120/70mmhg

PR -70bpm

RR-18cpm

Spo2 99% at room air 

Temperature -98.2F


SYSTEMIC EXAMINATION:

CVS: s1,s2 heard ,no Murmurs,jvp not raised 

RS: BAE,no added sounds ,NVBS

P/A: soft, non tender,bowel sounds can be heard 


CLINICAL IMAGES:









INVESTIGATIONS:

12/05/23
























MRI:











ORTHOPEDIC REFERRAL:










Diagnosis:

Dermatomyositis with pulmonary nocardiosis(resolved) with anaemia(normocytic normochromic) with Bilateral Avascular necrosis of femoral head

-Ficet and Artel stage 2 on right side,stage 3 on left side


Treatment:

T.Ultracet 1/2 tab PO QID

T.Wysolone 15mg PO OD

T.Azathioprine 100mg PO OD



SUMMARY:


Final Diagnosis:

Dermatomyositis with pulmonary nocardiosis(resolved) with anaemia(normocytic normochromic) with Bilateral Avascular necrosis of femoral head

-Ficet and Artel stage 2 on right side,stage 3 on left side


History:
Chief complaints:
37 years female  with chief complaints of

Pain of the left lower limb since 2 months


History of presenting illness:

Patient was apparently

asymptomatic 2years back, then

develored B/L joint pains (knee), Insidious in onset, gradually progressive

No aggrerating factors and relieved on medication.

History of distal muscle weakness , difficulty in mixing food, buttonning and unbuttoning of shirt.

H/O Proximal muscle weakness, difficulty in getting from squatting position.

 (diagnosed as dermatomyositis)

followed by 1 year back, cough with sputum, yellowish, non-foulsmelling non-blood tinged, moderate in amount, diagnosed as Pulmonary

Nocardiosis(cotrimoxazole)

Presently using:

T.Wysolone 20mg

T.Azathioprine 100mg

T.Naproxen 250mg

Now, since 2 months,

c/o Pain of the left lower limb., insidious in

Onset, gradually progressive, aggrevated by standing and walking, Not relieved with Medication(more since past 7 days),dragging type,

radiating down the leg upto ankle

 C/o difficulty in getting up from sitting position since 7 days

C/o tingling and numbness of both upper and lower limbs since 7 days

 polydypsia present,No polyuria, Polyphagia, Nocturia .

c/o Pedal edema since today afternoon, pitting type upto ankle

No c/o Fever, vomitings, decreased urine output, burning micturition,Chestpain,Palpitations

H/o diarrhea associated with pain abdomen 5 days back,watery stools 5-6 episodes per day,foul smelling,non blood stained


PAST HISTORY:

N/k/c/o HTN,DM,Thyroid disorders,Epilepsy 


PERSONAL HISTORY:

Diet-mixed 

Appetite-normal

Bowel and bladder-regular

Addictions-None


DAILY ROUTINE 

She daily wakes at 5 AM and takes bath and fresh up drinks tea at 7am and then she takes her breakfast  (idly/dosa) at 8am and takes her lunch at 1 pm which consisting of a vegetable curry and rice and after  she chit chat with her neighbors and lie down for some time and after that she watch TV and then eats her dinner at 8pm and goes to sleep at 9pm.


FAMILY HISTORY:

Insignificant


GENERAL EXAMINATION:

Patient is conscious coherent and cooperative 

No pallor ,icterus , clubbing,cyanosis,lymphadenopathy ,pedal edema

Vitals : 

BP- 120/70mmhg

PR -70bpm

RR-18cpm

Spo2 99% at room air 

Temperature -98.2F


SYSTEMIC EXAMINATION:

CVS: s1,s2 heard ,no Murmurs,jvp not raised 

RS: BAE,no added sounds ,NVBS

P/A: soft, non tender,bowel sounds can be heard 


Course in the hospital:

Patient got admitted for c/o pain of the left lower limb since 2 months and was investigated further and ortho opinion was taken on 13/5/23 and was adviced MRI pelvis with both hips.


MRI was done on 17/5/23

Impression:

Bilateral Avascular necrosis of femoral head

-Ficet and Artel stage 2 on right side,stage 3 on left side

-Mitchell type A on right,type C on left.

Mild left hip joint effusion


Ortho review referral was done on 17/5/23 qnd was adviced Left hip core decompression first and Right hip conservative trial and the same was explained to patient and patient attenders.

Patient wants some time to get prepared for the surgical intervention and wants to get discharged.patient said that she will come next week and get admitted.

Patient vitals are stable at time of discharge.


Treatment:

T.Ultracet 1/2 tab PO QID

T.Wysolone 15mg PO OD

T.Azathioprine 100mg PO OD


Advice:

Tab.Wysolone 15mg this week ---10mg next week ----5mg following week .

Tab.Azathioprine 100mg po/od.

As advised by orthopaedic team-

Tab.osteofos 70mg po/ 1tab / week for 2months.

Tab.shelcal 500mg po/bd ,After 2months po/od.


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