Presenting ByDr. Golam Muhamud (Suhash).
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.
• 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:
• 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
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
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.