Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with progressive proximal muscle weakness involving the pelvic and shoulder girdles, accompanied by persistent myalgia. Onset is insidious, characterized by difficulty rising from a chair, climbing stairs, and overhead reaching. Denies dysphagia, dyspnea, or skin rashes. Reports morning stiffness and generalized fatigue.
Clinical Examination Findings
Musculoskeletal exam reveals symmetric proximal muscle weakness (Grade 4/5). Tenderness to palpation noted in deltoids and quadriceps. No evidence of Gottronโs papules or heliotrope rash. Deep tendon reflexes are preserved and symmetric. Gait is waddling. No joint swelling or synovitis.
Treatment Protocol
Initiate high-dose systemic corticosteroids (Prednisone 1mg/kg/day) with a planned tapering schedule. Consider steroid-sparing agents (Methotrexate or Azathioprine) for long-term management. Physical therapy referral for range-of-motion exercises and muscle strengthening. Baseline labs: CK, LDH, Aldolase, and inflammatory markers (ESR/CRP).