Orthopedics Case No.6 Leg Cramps.

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Orthopedics Case No.6 Leg Cramps.

রেহানা ৩৫ বছর বয়স, শরীর দূর্বল,

lean and thin একজন মানুষ –পানি কম খায়- দিনে ৪-৫ গ্লাস- গত কিছুদিন থেকে তার সমস্যা, তার ভাষায় — স্যার/ম্যাডাম– হাঁটতে পারিনা, হাঁটতে গেলে পায়ের রগে টান খায়-

পায়ে কামড়ায়– ঝিমঝিম করে–

রেহানার প্রেশার দেখলেন, প্রেশার 100/60 mmHg.

রেহানাকে জিজ্ঞাস করলেন, কোমরে ব্যাথা আছে কিনা? বললো, না স্যার, কোমরে ব্যাথা নাই-

মেকানিকাল পেইনের সব প্রশ্ন করলেন, না এইটা মেকানিকাল পেইন মনে হচ্ছেনা—-

কিভাবে চিকিৎসা করবেন-?

কোন একটা পেশেন্ট যদি এমন complain নিয়ে আসে যে, তার পায়ের রগে টান খায়, তাহলে প্রথমত তার heal walking, toe walking করে নিবেন,sciatica exclude করে নিবেন, sciatica থাকলে আরো কিছু সমস্যা থাকবে- LBP থাকবে,

তারপর তার lower limb এর পালস দেখবেন,popliteal, posterior tibial and dorsalis pedis. এই পালস ক্লিয়ার থাকলে Peripheral vascular diseases exclude করবেন-

তারপর পেশেন্ট এর কিছু investigation দিবেন-

পেশেন্ট এর এই কন্ডিশন কে leg Cramps বলে-

এইটা Most common cause হচ্ছে dehydration, পেশেন্ট কোনো diuretics নেয় কিনা, তার হিস্ট্রি নিবেন,

প্রতিদিন কত গ্লাস পানি পান করে, তার হিস্ট্রি নিবেন–

diuretics নিলে সেটা বন্ধ করবেন,কিংবা proper water intake করতে বলবেন-

অত:পর পেশেন্ট Anaemic কিনা দেখুন,

পেশেন্ট এর bowel habit এর খবর নিন,

কোনো malabsorption আছে কিনা দেখুন, Malabsorption থাকলে পেশেন্ট এর Nutritional deficiency থাকবে,

তাই Malabsorption থাকলে তার চিকিৎসা করুন–

এনিমিয়া থাকলে তা কারেক্ট করুন-

patient এর malabsorption নাই,

water intake normal, তাহলে কি করবেন,

পেশেন্ট এর একটা CBC, Serum electrolyte, serum calcium করেন-

পটাশিয়াম কমে গেলে কিংবা ক্যালসিয়াম কমে গেলে leg cramps হতে পারে-

তাই পেশেন্ট কে পটাশিয়াম সমৃদ্ধ খাবার দিন, পটাশিয়াম যদি normal range এর lower limit এ থাকে, তাহলেও leg cramps হবে—

ভিটামিন ডি ডেফিসিয়েন্সি থাকলেও leg crams হবে-

এখন ধরুন, পেশেন্ট এর CBC and serum electrolyte নরমাল, পেশেন্ট আর কোনো ইনভেসটিগেশন করতে চাচ্ছেনা–

কিংবা পেশেন্ট প্রথম থেকেই কোনো ইনভেস্টগেশন করবেনা, চিকিৎসা চাচ্ছে,

তাহলে তার ক্ষেত্রে যে চিকিৎসা দিবেন-

Treatment Management :-

1…water intake কম হলে তারে water মিশিয়ে খাইতে হয়, এমন একটা ঔষধ দিয়ে দিন, যেমন alkuli syrup etc.

বলবেন, দৈনিক এক চামচ এক গ্লাস পানিতে মিশিয়ে ৪ বার, (২ মাস) [[ প্রতিদিন ৮-১০ গ্লাস পানি পান করার জন্য কাউন্সেলিং করবেন]]]

tab- Multivitamin যেখানে সব ভিটামিন থাকে,৷

Tablet 1.Nutrum Gold (AS A Multivitamin and Multiminarel AS A Multi-vitamin & Multi-mineral combined preparations).

0+0+1 দিবেন

Indications of Tablet:-Nutrum Gold (AS A Multivitamin and Multiminarel AS A Multi-vitamin & Multi-mineral combined preparations).

Nutrum Gold is indicated for the prevention and treatment of vitamins & minerals deficiencies. As a complete daily nutritional supplement, it is also indicated to meet the increased demand for vitamins and minerals in the conditions like physical and emotional stress, chronic diseases, infection illness, osteoporosis, injuries or wound, surgery, poor digestion, old age, pregnancy and lactation, poor appetite, excess dieting, exposure to environmental pollution, heavy exercise etc.

Composition of Tablet:-Nutrum Gold (AS A Multivitamin and Multiminarel AS A Multi-vitamin & Multi-mineral combined preparations).

Each tablet contains: Vitamin A 5000 IU, Vitamin C 60 mg, Vitamin D 400 IU, Vitamin E 30 IU, Vitamin K 25 mcg, Vitamin B1 (Thiamine) 1.5 mg, Vitamin B2 (Riboflavin) 1.7 mg, Vitamin B3 (Niacin) 20 mg, Vitamin B6 (Pyridoxine) 2 mg, Folic acid 400 mcg, Biotin 30 mcg, Pantothenate 10 mg, Calcium 162 mg, Iron 18 mg, Phosphorous 109 mg, Iodine 150 mcg, Magnesium 100 mg, Zinc 15 mg, Selenium 20 mcg, Copper 2 mg, Manganese 2 mg, Chromium 120 mcg, Molybdenum 75 mcg, Chloride 72 mg, Potassium 80 mg, Boron 150 mcg, Nickel 5 mcg, Silicon 2 mg, Tin 10 mcg, Vanadium 10 mcg, Lutein 250 mcg and Cyanocobalamin 6 mcg.

Pharmacology of Tablet:-Nutrum Gold (AS A Multivitamin and Multiminarel AS A Multi-vitamin & Multi-mineral combined preparations).

This is a film coated tablet, which combines 32 high potency vitamins and minerals. This preparation maintains a healthy body and active life-style.

Dosage & Administration of Tablet:-Nutrum Gold (AS A Multivitamin and Multiminarel AS A Multi-vitamin & Multi-mineral combined preparations).

One tablet daily or as recommended by the physician.

Interaction of Tablet:-Nutrum Gold (AS A Multivitamin and Multiminarel AS A Multi-vitamin & Multi-mineral combined preparations).

No drug interactions have been reported.

Contraindications of Tablet:-Nutrum Gold (AS A Multivitamin and Multiminarel AS A Multi-vitamin & Multi-mineral combined preparations).

This product is contraindicated in patients with known hypersensitivity to any of the ingredients.

Side Effects of Tablet:-Nutrum Gold (AS A Multivitamin and Multiminarel AS A Multi-vitamin & Multi-mineral combined preparations).

Generally, Nutrum Gold is well tolerated. Diarrhoea may occasionally occur during treatment with beta carotene and the skin may assume a slightly yellow discoloration. Vitamin C and vitamin E may cause diarrhoea and other gastrointestinal disturbances.

Pregnancy & Lactation of Tablet:-Nutrum Gold (AS A Multivitamin and Multiminarel AS A Multi-vitamin & Multi-mineral combined preparations).

Recommended by the consultation with physician.

Precautions & Warnings

Long term intake of high level of vitamin A (excluding that sourced from beta carotene) may increase the risk of osteoporosis in postmenopausal women.

Therapeutic Class of Tablet:-Nutrum Gold (AS A Multivitamin and Multiminarel AS A Multi-vitamin & Multi-mineral combined preparations).

Multi-vitamin & Multi-mineral combined preparations

Capsule2:- Defrol (40000 IU) (AS A Cholecalciferol (vitamin D3).AS A Vitamin in bone formation, Vitamin-D preparations).

সপ্তাহে একটা করে ৩ মাস

Indications of Capsule:- Defrol (40000 IU) (AS A Cholecalciferol (vitamin D3).AS A Vitamin in bone formation, Vitamin-D preparations).

Vitamin D3 deficiency can occur in people whose exposure to sunlight is limited and in those whose diet is deficient in vitamin D3.
Vitamin D3 is essential for the effective calcium and phosphate absorption required for healthy bones and teeth, preventing rickets, osteomalacia and osteoporosis.
Vitamin D3 is also essential to prevent pre-eclampsia during pregnancy and breast feeding as it is an essential nutrient for a growing infant.
Vitamin D3 has vital role on immunity boost up.

Pharmacology of Capsule:- Defrol (40000 IU) (AS A Cholecalciferol (vitamin D3).AS A Vitamin in bone formation, Vitamin-D preparations).

The active form of Vitamin D3, Calcitriol, exerts its effect by binding to the Vitamin D receptors (VDRs) which are widely distributed through many body tissues.Vitamin D3 has a half life of about 50 days as it is fat soluble.Vitamin D3 is absorbed in the small intestine and bound to specific a-globulins and transported to the liver where it is metabolised to 25-hydroxy Vitamin D3 (Calcidiol). A second hydroxylation to 1,25-dihydroxy Vitamin D3 (Calcitriol) occurs in the kidney. This metabolite is responsible for the vitamin’s ability to increase the absorption of calcium. Non-metabolised Vitamin D3 is stored in tissues such as fat and muscle.Vitamin D3 is eliminated via faeces and urine.

Dosage & Administration of Capsule:- Defrol (40000 IU) (AS A Cholecalciferol (vitamin D3).AS A Vitamin in bone formation, Vitamin-D preparations).

For capsule: Adults:

Treatment of Vitamin D3 deficiency: 40000 IU once weekly for 7 weeks. Doses for maintenance therapy is 1400-2000 IU/day. To confirm the target level of 25 hydroxyvitamin D, measurement of it should be determined 3-4 months after initiating the maintenance therapy.
Prevention of Vitamin D3 deficiency: 20000 IU every 4 weeks. Higher doses may be required in certain situations.
Addition to specific therapy for osteoporosis: 20000 IU once a month.

For capsule: Children (12-18 years):

Treatment of Vitamin D3 deficiency: 20000 IU once every 2 weeks for 6 weeks.
Prevention of Vitamin D3 deficiency: 20000 IU every 6 weeks.

For film-coated tablet: 1000 IU (1-2 tablets) daily, or as directed by physician. Take the medicine with food or within 1 hour after a meal.

For oroflash or chewable tablets: 1000 IU to 2000 IU daily, or as directed by physician. Take the medicine with food or within 1 hour after a meal. Place the tablet in mouth swallow after chewing.

For Syrup:
For patients with risk of Cholecalciferol deficiency:

0-1 yr: 400 IU/ day (2 ml)
>1 Yr: 600 lU/ day (3 ml)

For Cholecalciferol deficient patients:

0-1 yr: 2000 IU/ day (+50000 IU/week ) for 6 weeks
1 -18 yrs: 2000 IU/ day for 6 weeks.

Injection: Prevention:

Infants receiving Vitamin D enriched milk: ½ ampoule (0.5 ml) i.e. 1,00000 I.U. every 6 months.
Nursed infants or infants not receiving Vitamin D enriched milk or young children up to 5 years of age: 1 ampoule (1 ml) i.e. 2,00000 I.U. every 6 months.
Adolescents: 1 ampoule (1 ml) i.e. 2,00000 I.U. every 6 months during winter.
Pregnancy: ½ ampoule (0.5 ml) i.e. 1,00000 I.U. from the 6th or 7th month of pregnancy.
Elderly: ½ ampoule (0.5 ml) i.e. 1,00000 I.U. every 3 months. Digestive disorders, concomitant treatment with antiepileptics & other particular condition not described above; ½ ampoule (0.5 ml) i.e. 1,00000 I.U. or 1 ampoule (1 ml) i.e. 2,00000 I.U. every 3 or 6 months.

Injection: Vitamin D deficiency:

1 ampoule (1 ml) i.e. 2,00000 I.U. which can be repeated 1 to 6 months later. Or, as directed by the registered physician.

Interaction of Capsule:- Defrol (40000 IU) (AS A Cholecalciferol (vitamin D3).AS A Vitamin in bone formation, Vitamin-D preparations).

Many drugs cause Vitamin D3 deficiencies because they interfere with the absorption and metabolism of Vitamin D3 and includes Magnesium containing Antacids, Digoxin, Thiazide Diuretics, Cholestyramine, Cholistipol, Phenytoin, Phenobarbital, Orlistat,and Mineral Oil. Also, Corticosteroids, such as Prednisolone increase the need for Vitamin D3.

Contraindications

Vitamin D3 is contraindicated in all diseases associated with hypercalcaemia. It is also contraindicated in patients with known hypersensitivity to Vitamin D3 (or medicines of the same class) and any of the excipients. It is contraindicated if there is evidence of Vitamin D3 toxicity.

Side Effects of Capsule:- Defrol (40000 IU) (AS A Cholecalciferol (vitamin D3).AS A Vitamin in bone formation, Vitamin-D preparations).

Symptoms rarely include anorexia, lassitude, nausea & vomiting, diarrhea, constipation, weight loss, polyuria, sweating, headache, thirst, vertigo, and raised concentrations of calcium and phosphate in plasma and urine.

Pregnancy & Lactation of Capsule:- Defrol (40000 IU) (AS A Cholecalciferol (vitamin D3).AS A Vitamin in bone formation, Vitamin-D preparations).

Studies have shown safe use of doses up to 4000 IU during pregnancy. The recommended daily intake for pregnant women is 400 IU, however, in women who are considered to be Vitamin D3 deficient a higher dose may be required. During pregnancy women should follow the advice of their medical practitioner as their requirements may vary depending on the severity of their disease and their response to treatment

Vitamin D3 and its metabolites are excreted in breast milk. Overdose in infants induced by nursing mothers has not been observed; however, when prescribing additional vitamin D3 to a breast-fed child the practitioner should consider the dose of any additional vitamin D3 given to the mother.

Therapeutic Class of Capsule:- Defrol (40000 IU) (AS A Cholecalciferol (vitamin D3).AS A Vitamin in bone formation, Vitamin-D preparations).

Vitamin in bone formation, Vitamin-D preparations

Tablet 3- Biocal Dx (600mg +400IU) (As a (Algae Calcium +Vitamin D3) AS A Specific mineral & vitamin combined preparations)

0+1+0 (2 month) .

Indications of Tablet:- Biocal Dx (600mg +400IU) (As a (Algae Calcium +Vitamin D3) AS A Specific mineral & vitamin combined preparations)

Biocal-DX is indicated in following cases-

Treatment of osteoporosis, rickets, osteomalacia, tetany and hypoparathyroidism
In pregnancy and lactation due to increased demand
In kidney disease and pancreatitis
During therapy with antiseizure medications
The prevention and treatment of Calcium and Vitamin D3 deficiency

Composition of Tablet:- Biocal Dx (600mg +400IU) (As a (Algae Calcium +Vitamin D3) AS A Specific mineral & vitamin combined preparations)

Each film coated tablet contains-

Calcium Carbonate (Algae Source) BP 1250 mg equivalent to elemental Calcium 500 mg.
Vitamin D3 200 IU as Cholecalciferol USP.

Pharmacology of Tablet:- Biocal Dx (600mg +400IU) (As a (Algae Calcium +Vitamin D3) AS A Specific mineral & vitamin combined preparations)

Calcium (Algae Source) is an essential element and plays vital role in the body. It makes body’s framework stronger by building bones. Clinical evidence suggests that calcium is useful for prevention and treatment of osteoporosis and associated fractures. Vitamin D3 is also essential for healthy bones as it aids in calcium absorption from the Gl tract. In addition to this it stimulates bone formation. Controlled clinical studies show that Calcium and Vitamin D3 have synergistic effects on bone growth as well as in osteoporosis and fracture prevention.

Dosage & Administration of Tablet:- Biocal Dx (600mg +400IU) (As a (Algae Calcium +Vitamin D3) AS A Specific mineral & vitamin combined preparations)

Usual adult dose: 1 tablet in the morning and 1 tablet at night. Tablet should be taken orally.

Interaction of Tablet:- Biocal Dx (600mg +400IU) (As a (Algae Calcium +Vitamin D3) AS A Specific mineral & vitamin combined preparations)

With medicine:

Calcium salts reduce absorption of bisphosphonates, ciprofloxacin, fluorides, iron, levothyroxine, tetracycline and zinc
Absorption of calcium salts is reduced by corticosteroids
Increased risk of hypercalcemia when Calcium and Vitamin D3 given with thiazides and related diuretics

With food and others: No clinically significant food drug interaction have been reported.

Contraindications of Tablet:- Biocal Dx (600mg +400IU) (As a (Algae Calcium +Vitamin D3) AS A Specific mineral & vitamin combined preparations)

Hypocalcemia and hypercalciuria
Metastatic calcification
Hypersensitivity to any of the components of Calcium and Vitamin D3 preparation

Side Effects of Tablet:- Biocal Dx (600mg +400IU) (As a (Algae Calcium +Vitamin D3) AS A Specific mineral & vitamin combined preparations)

Common side effects of Calcium and Vitamin D3 may include an irregular heartbeat, nausea, dry mouth, weakness, headache, a metallic taste in mouth, muscle or bone pain and drowsiness. Rare side effects are high amount of Calcium in blood, constipation, diarrhoea, loss of appetite.

Pregnancy & Lactation of Tablet:- Biocal Dx (600mg +400IU) (As a (Algae Calcium +Vitamin D3) AS A Specific mineral & vitamin combined preparations)

During pregnancy & lactation: Calcium and Vitamin D3 should be used considering the risk-benefit ratio.

Precautions & Warnings of Tablet:- Biocal Dx (600mg +400IU) (As a (Algae Calcium +Vitamin D3) AS A Specific mineral & vitamin combined preparations)

Caution should be taken in patients with renal impairment, sarcoidosis, hypercalcemia and hypercalciuria.

Use in Special Populations

Not recommended for children under 12 years.

Overdose Effects

At high doses it may result in nausea, vomiting, dizziness, anorexia, abdominal cramps, headache, constipation etc. Treatment includes cessation of therapy & adequate rehydration.

Therapeutic Class of Tablet:- Biocal Dx (600mg +400IU) (As a (Algae Calcium +Vitamin D3) AS A Specific mineral & vitamin combined preparations)

Specific mineral & vitamin combined preparations

Capsule 4:-E- Cap 200 (AS A Vitamin E Herbal and Nutraceuticals, Vitamin-E Preparations).

1+0+0 (2 month)

Indications of Capsule :-E- Cap 200 (AS A Vitamin E Herbal and Nutraceuticals, Vitamin-E Preparations).

1+0+0 (2 month)

E-Cap is indicated for the treatment and prevention of E-Cap deficiency. E-Cap (d-alpha tocopherol) is also suggested to use as an antioxidant to promote, prevent and treat various health conditions such as-

Alzheimer’s Disease
Rheumatoid Arthritis Pain
Nerve Damage caused by Chemotherapy
Male Infertility
Age-related Macular Degeneration
Keratectomy
Premenstrual Syndrome
Painful Menstrual Periods
Heart Disease (to improve effectiveness of nitrates) etc.

Pharmacology of Capsule :-E- Cap 200 (AS A Vitamin E Herbal and Nutraceuticals, Vitamin-E Preparations).

Vitamin E acts as an antioxidant in the body. Vitamin E protects polyunsaturated fatty acids (which are components of cellular membrane) and other oxygen-sensitive substances such as vitamin A & vitamin C from oxidation. In premature neonates irritability, edema, thrombosis and hemolytic anemia may be caused due to vitamin E deficiency. Creatinuria, ceroid deposition, muscle weakness, decreased erythrocyte survival or increased in vitro hemolysis by oxidizing agents have been identified in adults and children with low serum tocopherol concentrations.

Dosage & Administration of Capsule :-E- Cap 200 (AS A Vitamin E Herbal and Nutraceuticals, Vitamin-E Preparations).

Age-related Macular Degeneration: Vitamin E 400-600 IU daily.

Heart Disease (to improve effectiveness of Nitrates): Vitamin E 200 IU three times daily.

Dementia/Alzheimer’s Disease: Vitamin E 800-2000 IU one-two times daily.

Rheumatoid Arthritis Pain: Vitamin E 600 IU daily.

Improving Male Infertility: Vitamin E 200-600 IU daily.

Menstrual Syndrome: Vitamin E 400 IU daily.

Painful Menstrual Period: Vitamin E 200 IU daily.

Interaction of Capsule :-E- Cap 200 (AS A Vitamin E Herbal and Nutraceuticals, Vitamin-E Preparations).

E-Cap may impair the absorption of E-Cap A & function of E-Cap K and potentiates the effect of Warfarin.

Contraindications of Capsule :-E- Cap 200 (AS A Vitamin E Herbal and Nutraceuticals, Vitamin-E Preparations).

Contra-indicated in patients with a known hypersensitivity to vitamin E. Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrose-isomaltase insufficiency should not take this medicine.

Side Effects of Capsule :-E- Cap 200 (AS A Vitamin E Herbal and Nutraceuticals, Vitamin-E Preparations).

Diarrhoea & abdominal pain may occur with doses greater than 1000 IU daily.

Pregnancy & Lactation of Capsule :-E- Cap 200 (AS A Vitamin E Herbal and Nutraceuticals, Vitamin-E Preparations).

There is no evidence of the safety of high doses of vitamin E in pregnancy, therefore should not use in pregnancy especially in the first trimester. No information is available on excretion in breast milk, therefore it is advisable not to use during lactation.

Precautions & Warnings of Capsule :-E- Cap 200 (AS A Vitamin E Herbal and Nutraceuticals, Vitamin-E Preparations).

E-Cap has been reported to increase bleeding tendency in vitamin K deficient patients or those taking anticoagulant treatments, it is therefore recommended to monitor the prothrombin time and international normalised ratio (INR) to detect any changes in haemostasis. E-Cap has been reported to increase the risk of thrombosis in patients predisposed to this condition, including patients taking oestrogens. This finding has not been confirmed but should be borne in mind when selecting patients for treatment, in particular women taking oral contraceptives containing oestrogens.

Overdose Effects of Capsule :-E- Cap 200 (AS A Vitamin E Herbal and Nutraceuticals, Vitamin-E Preparations).

Transient gastrointestinal disturbances have been reported with doses greater than 1000 IU daily and where necessary, general supportive measure should be employed.

Therapeutic Class of Capsule :-E- Cap 200 (AS A Vitamin E Herbal and Nutraceuticals, Vitamin-E Preparations).

Herbal and Nutraceuticals, Vitamin-E Preparations

Calcium level high hole….15/16 tokhn ki rx dibo?

Answer Is:-hypercalcemia এর কারণ evaluation করতে হবে–

Most common cause hyperparathyroidism

পেশেন্ট এর ডিটেইলস হিস্ট্রি নিতে হবে, Multiple myeloma হলেও এমন হয়-

অতিরিক্ত ভিটামিনি ডি সাপ্লিমেন্টারী নিলেও এমন হয়-

সব নরমাল থাকলে fluid intake increase করলেই হবে–

E cap er role ki??

Answer IS:-Vitamin E deficiency also associated with leg Cramps

ইলেক্ট্রোলাইট ইমব্যালেন্স থাকলে Cause evaluate করে চিকিৎসা দিবেন

Raiyyan Tahsan.Date:23-01-2025 Thursday Time:-6-50-55PM

Raiyyan Tahsan

Raiyyan Tahsan