Manjunath
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  • 1. Dr. Sikha N Mathew
  • 2. Patient name : Manujanath Age: 56 years OP no: 2675558
  • 3. Manjunath, a 56 year old male patient, presented with complaints of • Severe back pain- gradually progressive, non radiating, increasing intensity to the point where he was unable to sleep properly • Inability to stand up from the sitting or squatting position • Inability to climb up the stairs • Generalized weakness, easy fatiguability • Increased swelling of the hands, limbs and face • Increased salivation and burning sensation of the mouth All these symptoms began 20-25 days back and has increased in intensity since then. • Decreased appetite and weight loss of >10 kg over 6 months
  • 4. No c/o fever/ cough/chest pain/ SOB/ bleeding manifestations/ vomiting/ loose motion /dysuria. No c/o tingling numbness/ slipping of sandals from the feet/ inability to comb hair/ to eat food with his hands/ altered sensorium/ drooping of eyelids in the evening. Known case of DM since 17 years (on Tab. Glimepiride- Metformin) and chronic Pancreatitis with pancreatic pseudocyst s/p sphincterotomy and stenting. No h/o thyroid problems or steroid intake. Chronic smoker and alcoholic who had his last drink 20-25 days back. Other medications (prescribed when he visited OPD on 19.09.13) Cap. Panlipase, T. lasix 20mg OD, Cap. Zevit
  • 5. Conscious, oriented Poorly built, poorly nourished Pallor+++, Icterus+, Anasarca, Glossitis- bald beefy tongue B/L entropion and watering of both eyes Pulse: 99/min BP: 120/70 mmHg Saturation : 95% on RA RR:18/min CVS: S1S2+ RS: NVBS+ PA: soft, non tender BS+ CNS: HMF: Conscious oriented, speech was fluent Cranial nerves: no deficits Power: Able to move his limbs, Pt unable to sit up and get out of bed without support, Pt able to walk without support. 5/5 in upper limbs Hip and knee - flexion and extension: 3/5 on left, 4/5 on right Ankle dorsiflexion and plantar flexion: 5/5 Tone: normal Sensory system intact DTR +, both plantars flexor
  • 6. • True weakness is the inability to perform a desired movement with normal force because of a reduction in muscle strength. • It has to be distinguished from malaise due to medical conditions – perceived
  • 7. INHERITED MUSCULAR DYSTROPHIES NEUROMYOTONIA CONGENITAL – minicore/nemaline/centronuclear MITOCHODRIAL MYOPATHIES FAMILIAL PERIODIC PARALYSIS INFLAMMATORY MYOPATHIES- glycogen storage / lipid storage disorders ACQUIRED DRUG-INDUCED – glucocorticoids, colchicine, penicillamine, etc CUSHING’S SYNDROME – protein degradation, mitochondrial alterations, decreased sarcolemmal excitability ALCOHOL INDUCED POLYMYOSITIS- proximal weakness with chronic inflammation of muscles, esophageal dysmotility, foot drop (u/l or b/l), +/- ILD, mainly females DERMATOMYOSITIS- polymyositis with gottron’s lesions, calcinosis of skin, joints and vasculitis, mainly females INCLUSION BODY MYOSITIS- polymyositis with distal muscle involvement MYOSITIS OSSIFICANS- heterotropic calcification at sites of blunt trauma, within muscles mainly quadriceps, glutei, pectoralis, intercostal spaces RHABDOMYOLYSIS sec to infection, crush injuries, medications, toxins, etc. HYPOTHYRODISM (abnormal glycogen accumulation, type 1 fibre atrophy) HYPERTHYROIDISM (AchE degradn and MEP structural changes- increased firing- fatigue)
  • 8. • Alcoholic myopathy, in acute or chronic forms, are rare. • Only 8 patients out of 510 patients studied showed some form of alcoholic myopathy, mainly due to an excessive accumulation of triglycerides in the muscles. • Seen more prominently in patients who drink over 100 gms of alcohol for a period of more than 3 years is at higher risk. • The relation between alcohol and muscles- • Acute rhabdomyolytic process • Swollen tender muscles accompanied by severe proximal muscle weakness • May cause acute renal failure – dialysis. • Spontaneous recovery is the rule rather than the exception i.e if patient withdraws from alcohol successfully. • Pathophysiological basis unknown. British Medical Journal, Volume 288, Page 5 84, 25 Feb1984.
  • 9. • Decrease in type 2 (fast twitch, anaerobic, glycolytic) muscle fibers • Acetaldehyde adducts – contractile defects and muscle weakness • Loss of dystrophin • Reduced rates of muscle synthesis • Increased production of cholestrol • Generation of free radicals + Low serum levels of selenium and tocopherol 60% of 150 subjects studied had some form of skeletal muscle damage on biopsy- more common in western hemisphere.
  • 10. TYPES ONSET GENDE R FEATURES Duchenne Most common, childhood Males Dystrophin glycoprotein complex defect – disruption of outer muscle memb- weakness and wasting, early demise Becker’s Less severe form of Duchenne’s Males Partially functional dystrophin, survival into old age Congenital Gen weakness + joint deformities, slow progression, early demise Emery Dreiffus Childhood Gen weakness, wasting leading to teenage contractures, distal to proximal progress, sudden death due to arrhytmias, strokes Limb girdle Recessiv e genes- childhoo d Dominan t genes- adult Both Affects proximal muscles, normal life with death due to cardio-pulmonary complications. Myotonic Dominant Delayed relaxation, wasting, weakness Oculopharyngeal Affects face, eyes and pharynx f/b proximal muscle weakness, 40-70 yrs
  • 11. • GRBS: 121 mg/dl • ECG: Sinus tachycardia • VBG: • MRI spine after Neurology reference • Planned for admission. pH pCO2 Hb Na K Cl Lac Creat Hco3 Hct 7.446 37.6 6.0 127 3.3 97 5.1 0.95 25.5 19.0
  • 12. USG Abdomen: • CLD with dilated portal veins • Chronic calcific pancreatitis • Cholelithiasis • Moderate ascites MRI spine: C4-C7 and L2-S1 disc bulges causing thecal compression and neural compromise. OGD: Esophageal ulcer (awaiting biopsy report) with congestive gastropathy ENMG: severe motor and sensory neuropathy
  • 13. UNILATERAL BILATERAL LIFE THREATENING OTHERS CVA Multiple sclerosis Hemiplegic migraine Todd’s paralysis LIFE THREATENING OTHERS CVA(Brainstem) Muscular dystrophy Spinal cord inflammation Alcoholic myopathy Spinal cord compression Myositis GBS Botulism Myasthenia Gravis OP poisoning Tick paralysis
  • 14. LIFE THREATENING OTHERS SEPSIS HYPOTHYROIDISM ACS INFECTION HYPOGLYCEMIA ANEMIA DYSELECTROLYTEMIA/ PERIODIC PARALYSIS ( K, Ca, Mg, PO4) DEHYDRATION/HYPOVOLEMIA CARBON MONOXIDE POISONING PRE-SYNCOPE THYROTOXICOSIS MEDICATIONS ( beta blockers, diuretics, chemo, antibiotics, antimalarials, alcohol..) POLYMYALGIA RHEUMATICA AGE-RELATED