CASE PRESENTATION

ON

Presenting ByDr. Golam Muhamud (Suhash).

Prepared By-

Dr. Md Nazrul Islam

MBBS, M .sc. (B M E).

 She has h/o wt. loss, and loss of appetite but she has /had no complaints of pain, swelling and deformity in other parts of the body. She has no history of cough , haemoptysis, DM , HTN and asthma. With these complaints she got herself admitted into Shaheed Suhrawardy Medical college Hospital for better management.

 She had no history of tuberculosis.

Drug history:

H/O taking analgesic for 3 months but could not mentioned the name of drugs.

None of her family member suffered from such illness. Personal history:

Nothing contributory

 MP-4 to 6 days
MC-regular Age of menarche-13yrs.

Immunized against Tuberculosis & Tetanus

Appearance- Ill looking Body builds- Below average Co-operation- Co-operated Decubitus- Supine Anaemia- Moderate Jaundice- Absent Cyanosis- Absent Clubbing- Absent Koilonychia-Absent Lekonychia- Absent Lymph nodes- Not palpable Dehydration- No sign Pulse - 84 Beat/min Blood pressure- 100/60mm of Hg

Temperature-normal Respiratory rate-16/min

Look-

Fluctuation test- negative, Trans-illumination test-negative, Patellar tap test- negative. Shortening of limb - 3 cm. Muscle wastingThigh 4 cm. Leg 2 cm

Distal neurovascular status- normal Regional lympnodesnot enlarged.

Movement: walk with support. Left knee (ROM) Active flexion -Absent Active extension-Absent Patellar movement-Absent Left hip & ankle: normal range of movement

Locomotor system Gait: Can walk with support Inspection:Flexion attitudeLeft knee(20 degree) Palpation: Tenderness affected area. Spine: Normal

Higher psychic function: Normal Cranial Nerve examination: Normal Motor function: Inspection: Gross Muscle wasting in left thigh & leg.

Deep tendon reflex: All jerks are present & normal Sensory function test: All the sensory functions are normal.

 Inspection: Normal in size & shape of the chestRespiratory rate: 16 /min Palpation: Trachea centrally placed, normal chest expansibility Percussion: Resonant all over the chest except right upper, middle and lower zone where dullness is present. Auscultation: Bronchial breathing sound with diminished breathing sound in Rt. Upper middle and lower zone.

 Pulse: 84 bts/ min B.P. 110/60 mm of Hg JVP: Not raised. Inspection: NAD Palpation: Apex beat in Lt 5thintercostal space,
Percussion: superficial cardiac dullness presence over the

precordium.

Auscultation: s1& s2 is audible

 Inspection: nothing abnormality detected Palpation: soft, non tender Percussion: tympanic Auscultation: bowel sound present Per-rectal examination: normal findings.

Ms. Fatema, 18 years ill-looking, moderately anaemic, non icteric, nondiabetic, normotensive woman coming from Mirpur, Dhaka admitted in ShaheedSuhrawardy Medical College Hospital with thecomplaints of pain, just above the left knee joint 3 months back , swelling above the left knee joint 2 months back and inability to walk for 1month.

 The pain was initially mild , fixed, non radiating, aching in nature but gradually it becomes intolerable which was aggravated during walking and worse at night & incompletely relived by taking NSAIDs.Thispain was not associated with fever. She also noticed an ill defined swelling above left knee joint which was initially.

Small in size then it increases rapidly to a large size.It is associated with pain but not related to trauma. She also gives H/O inability to walk due to pain,swelling and restriction of movement. She gives H/O wt loss,loss of appetite but she has no H/O pain,swelling,deformity in other parts of body.

 On local examination- an ill defined diffuse swelling occupying over the supracondylar region of the left thigh with shiny skin and presents of engorged vein and wasting of the thigh and leg.

She has a deformity of knee and cannot walk without support.

 The surface of swelling smooth, margin- illdefined, local temperature-raised , tenderness present, over lying skin is free, consistency-hard, not movable and fixed with underlying structure.

Shortening of the left limb was found 3 cm than the right. She was unable to walk without support.

 There was gross muscle wasting in left Lower limb, measuring thigh- 4cm, leg- 2 cm. Neuromuscular status of left lower limb normal and regional lympnodes are not enlarged.Movement of the left knee joint absent hip and spine are normal. On respiratory system examination-there was a dullness in Rt upper and lower zone of lung and breath sound also diminished in same area.Other system examination reveals no abnormality.

 Extensive bone destruction is seen in the left lower femoral shaft, condyles and tibialcondyles with soft tissue extension. peripheral calcification also seen. Bone destruction also seen in L5 vertebra.

Multiple metastatic nodules in both lungs along with Rt. Sided Hydro-pneumothorax-

 S. creatinine Blood urea S. calcium

0.6 mg/ dl 30 mg / dl 7.5 mg / dl 110 IU/ L

S. alkaline phosphates

SGPT:26 IU/L , SGOT :33 IU/L

S. bilirubin:1.0 mg/dl

FNAC- Sarcomatous leison,suggestive of osteosarcoma. Biopsy (incisional): Feature of osteosarcoma with osteod formation and many giant cells.