Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with progressive, symmetric proximal muscle weakness involving the pelvic and shoulder girdles. Reports difficulty with climbing stairs, rising from a chair, and overhead reaching. Denies sensory deficits, bowel/bladder incontinence, or acute trauma. Onset is insidious over [weeks/months]. Associated symptoms include [fatigue/myalgia/dysphagia/dyspnea]. No history of recent viral illness or medication changes.
Clinical Examination Findings
Musculoskeletal: Symmetric proximal muscle weakness (Grade [X]/5) noted in deltoids, hip flexors, and quadriceps. No muscle atrophy or fasciculations observed. Deep tendon reflexes are preserved. Skin: No Gottronโs papules or heliotrope rash (consistent with Polymyositis rather than Dermatomyositis). Pulmonary: Clear to auscultation; no crackles. Cardiovascular: Regular rate and rhythm, no murmurs. Neurological: Cranial nerves II-XII intact; no sensory deficits.
Treatment Protocol
Initiate high-dose systemic corticosteroids (Prednisone [X] mg/kg/day). Consider steroid-sparing agents (Methotrexate or Azathioprine) for long-term management. Physical therapy referral for range-of-motion exercises and muscle strengthening. Monitor serum CK levels, LDH, and AST/ALT periodically. Advise calcium and Vitamin D supplementation for bone protection.