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July 1, 2011

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32 . .

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1

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15 ( 5)

5-6

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. Enalapril,

ASA, Vit.B

1

.

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IVDU , unsafe sex

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40( 2-3 )

30 (?)

4

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V/S : BT36.8oC, BP 123/79 mmHg,

PR 87 bpm, RR 18 /min

GA : A Thai male, fully concious

HEENT: Not pale conjunctivae, anicteric sclerae,superficial lymph node impalpable, no oral thrush

Heart : RegularS1S2, no murmur

Lung : Normal breath sound, no adventitious sound

Abdomen: Soft, not tender, liver and spleen not palpable Ext : Muscle atrophy both arms, forearm, intrinsic muscle

both hands

Muscle atrophy both thigh (calf muscle not atrophy)

No rash, no pitting edema, no point of tenderness

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Neurological Exam:

- Fully conscious, normal speech

- Pupil 3mm RTLBE, VA normal both eyes- CN intact, no nystagmus, full EOM both eyes

- Intact pin-prick sensation and propioception

- DTR decrease (absent to 1+) all

- Clonus negative , BBK plantar flexion both

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Motor Power Right Left

Deltoid I II

Biceps III III

Triceps III III

Wrist extension III IIIWrist flexion III III

Hand grip IV IV

Hip Flexion I I

Quadriceps II II

Hamstring II III

Tibialis anterior II III

Gastrosoleus II III

EHL II III

Toes flexion V V

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Progressive symmetrical proximal muscleweakness

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CBC

Hct 44.4 %

Hb 14.8 g/dL

WBC 7900 /ul (N 67%, L 20%, Mono 6%)

Plt 249,000 /ul

MCV 93.5 fl

RDW 13.9Normochromic Normocytic

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Electrolyte

BUN /Cr 11.8/0.5

Na 138K 4.3

Cl 103

HCO3 27.8

Ca 10.2Mg 2.3

PO4 3.8

LFTTP 8.7

Alb 5.0Glob 3.7

Chol 174

TB/DB 0.4/0.1

AST 49

ALT 28

ALP 81

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CK : 1514

Coagulation : PT 11.56

INR 1.12PTT 30.15

ESR : 13

HbA1C : 5.5

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Chest X-Ray :No cardiomegaly, no pulmonary infiltration

Echocardiography :LV dilated with global hypokinesiaLVEF 22.8%, no valve lesionRA+RV+LA normalImp : DCM

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progressive proximal muscleweakness.. Locate lesion LMN

muscle congenital vs acquired congenital muscular dystrophy distribution muscle involved

congenital muscular dystrophySummary: Becker delayed

onset pattern confirm muscle biopsy

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