PW Health Clinic

[nasirjavaid]

Dear docs I feel pain in lower legs for many years, its like very tired feeling. But since last week I am feeling severe muscle pain in my left leg on outer side. It agrevates while walking when I push forward with it. Also feel pain in ankle joint.

BACKGROUND: 4 years ago I slipped and twisted my ankle and front part of left foot. Went to shaikh zaid hospital, got xray and they said its nothing wrong and gave rubbing cream which I used for a week and felt better.
But still some times I feel pain in front foot when press on groung while walking. I suspect it can be due to this. Any suggestions what to do or from where to get it checked by a good orthopedic?
I am software engineer so most of the is spent in front of laptop sitting on chair. Also feel some pain in left hand joint.

My mother had rheumatoid arthritis.

Thanks a lot in advance.

[s55]

A quick off topic question related to medical: Is there a different passing criteria for USMLE for US citizens and non-US citizens? I heard its easier for US citizens than non-US citizens. Thanks!

[Glioblastoma]

Dear docs I feel pain in lower legs for many years, its like very tired feeling. But since last week I am feeling severe muscle pain in my left leg on outer side. It agrevates while walking when I push forward with it. Also feel pain in ankle joint.

BACKGROUND: 4 years ago I slipped and twisted my ankle and front part of left foot. Went to shaikh zaid hospital, got xray and they said its nothing wrong and gave rubbing cream which I used for a week and felt better.
But still some times I feel pain in front foot when press on groung while walking. I suspect it can be due to this. Any suggestions what to do or from where to get it checked by a good orthopedic?
I am software engineer so most of the is spent in front of laptop sitting on chair. Also feel some pain in left hand joint.

My mother had rheumatoid arthritis.

Thanks a lot in advance.

The symptoms you are describing can be either its arterial insufficiency known as claudication or it may be due to disc herniation in your lumbar region or lumber strain or spinal stenosis, may be a DVT or muscular pain due to improper positioning while sitting for long periods.

For arterial insufficiency along with pain in leg while walking pain disappears while at rest, skin changes on leg like disappearance of hair or nail changes on foot are seen. For diagnosis ankle brachial index, doppler ultrasound of leg, last test if required after doppler is angiography.

Disc herniation or lumber strain very common has back pain and pain radiates into the leg might worsen while walking, but no skin or hair or nail changes. pain increases with back flexion and relieved by back extension. Do a straight leg raising test and get a back x ray, for confirmed diagnosis MRI lumber spine screening protocol.

Spinal stenosis pain in legs which is aggravated with walking improved with rest very similar to claudication. Pain relievedif person walks with back flexed like pushing a grocery trolley cart or while cycling and pain increased with back extension. Only one test for diagnosis MRI lumbar spine screening protocol.

DVT is in my differential diagnosis because most important thing in your history is prolong sitting. To test it doppler ultrasound or compression ultrasound.

Most likely my diagnosis in your case would be lumber strain or disc herniation or muscular strain due to improper positioning. Treatment if lumber strain or disc herniation is the cause, will be, sleep on a flat hard bed like a piece of cardboard or floor for 2 weeks, avoid lifting heavy weights, medicines if you like diclofenac for pain relief and a muscle relaxant like anyone (tizanidine, baclofen or orphenadrine + paracetamol). You can also buy a lumber corset for spine stabilization.

It is highly unlikely on your symptoms to be rheumatoid arthritis(RA) but if you want to get tested get a rheumatoid factor(RF) but it is highly unspecific test most accurate for RA is anti cyclic citrullinated peptide(anti CCP).

Highly unlikely your ankle twisting history is causing this, symptoms you are telling are of lumber spine and RA rarely affects lumber spine, as I said your prolonged sitting with improper positioning will be causing it.

[Glioblastoma]

A quick off topic question related to medical: Is there a different passing criteria for USMLE for US citizens and non-US citizens? I heard its easier for US citizens than non-US citizens. Thanks!

I have cleared all my steps only step 3 licensing part is remaining. I would be applying next year. Its easier for green card holders aka US residents to get a residency only if scores are good all exams first attempt and CV is strong. Even if you are not a resident all that determines your fate would be first of all scores then all exams first attempt and then electives, research publications/experience, observerships lastly also years since graduation. But still US residents have a slight edge.

Another appeal to all PW to prey for my exam and residency. Thanks alot.

[Glioblastoma]

One more thing s55 the scores I was saying, criteria for scores is same for all international medical graduates that is danger zone is anything below 230 in any step, but I have seen people match even at 210 the thing which matters then is the lower your scores the more you have to cover them up with brilliant electives, observerships and research, but even those with high scores do not relax get into any available opportunity for electives, observerships or research. US citizens have advantage as many research opportunities are available to them and those programmes that do not want to get in the mess of visa processing and its related stuff.

[invincible_doc]

A quick off topic question related to medical: Is there a different passing criteria for USMLE for US citizens and non-US citizens? I heard its easier for US citizens than non-US citizens. Thanks!

No. Its the same exam with the same criteria for ImGS and AMGs.

[nasirjavaid]

The symptoms you are describing can be either its arterial insufficiency known as claudication or it may be due to disc herniation in your lumbar region or lumber strain or spinal stenosis, may be a DVT or muscular pain due to improper positioning while sitting for long periods.

For arterial insufficiency along with pain in leg while walking pain disappears while at rest, skin changes on leg like disappearance of hair or nail changes on foot are seen. For diagnosis ankle brachial index, doppler ultrasound of leg, last test if required after doppler is angiography.

Disc herniation or lumber strain very common has back pain and pain radiates into the leg might worsen while walking, but no skin or hair or nail changes. pain increases with back flexion and relieved by back extension. Do a straight leg raising test and get a back x ray, for confirmed diagnosis MRI lumber spine screening protocol.

Spinal stenosis pain in legs which is aggravated with walking improved with rest very similar to claudication. Pain relievedif person walks with back flexed like pushing a grocery trolley cart or while cycling and pain increased with back extension. Only one test for diagnosis MRI lumbar spine screening protocol.

DVT is in my differential diagnosis because most important thing in your history is prolong sitting. To test it doppler ultrasound or compression ultrasound.

Most likely my diagnosis in your case would be lumber strain or disc herniation or muscular strain due to improper positioning. Treatment if lumber strain or disc herniation is the cause, will be, sleep on a flat hard bed like a piece of cardboard or floor for 2 weeks, avoid lifting heavy weights, medicines if you like diclofenac for pain relief and a muscle relaxant like anyone (tizanidine, baclofen or orphenadrine + paracetamol). You can also buy a lumber corset for spine stabilization.

It is highly unlikely on your symptoms to be rheumatoid arthritis(RA) but if you want to get tested get a rheumatoid factor(RF) but it is highly unspecific test most accurate for RA is anti cyclic citrullinated peptide(anti CCP).

Highly unlikely your ankle twisting history is causing this, symptoms you are telling are of lumber spine and RA rarely affects lumber spine, as I said your prolonged sitting with improper positioning will be causing it.

Thank you so much for your detailed diagnosis. After reading your reply I also feel it could be due to sitting posture as my sitting is too long and I feel neck and shoulder muscles pulled.

But I don't think it could be disk herniation or pinched nerve as pain is more like when muscles feel after first time exercise - Tired.
Also I never felt any kind of back pain... (only feel lower back pain when standing for 30-60 minutes, which goes away with couple of minutes of sitting or resting)

I feel while sitting on chair my thighs are pressed against chair seat and that could have restricted blood supply to legs as i feel muscle tiredness and pain of being pressed against seat. This pain of legs and thighs gets reduced after "Maalish". Whats your opinion about this.

Ankle pain could also be due to sitting on floor or bed with legs crossed like we sit in yoga. in this case ankle is little bit twisted so I started sitting the other way and it seems working for ankle..

but the pain in front part of foot when pressed against floor seems from the bone and looks like has roots with the ankle twist (front part of foot twisted also at that time).

So do you suggest i should have xray of foot and ankle from some other hospital? also please name the x-ray test for this situation.

I was wondering could the tiredness feeling (don't want to move much) most of the time be due to hypothyroid ?

Cheers!

[Glioblastoma]

Thank you so much for your detailed diagnosis. After reading your reply I also feel it could be due to sitting posture as my sitting is too long and I feel neck and shoulder muscles pulled.

But I don't think it could be disk herniation or pinched nerve as pain is more like when muscles feel after first time exercise - Tired.
Also I never felt any kind of back pain... (only feel lower back pain when standing for 30-60 minutes, which goes away with couple of minutes of sitting or resting)

I feel while sitting on chair my thighs are pressed against chair seat and that could have restricted blood supply to legs as i feel muscle tiredness and pain of being pressed against seat. This pain of legs and thighs gets reduced after "Maalish". Whats your opinion about this.

Ankle pain could also be due to sitting on floor or bed with legs crossed like we sit in yoga. in this case ankle is little bit twisted so I started sitting the other way and it seems working for ankle..

but the pain in front part of foot when pressed against floor seems from the bone and looks like has roots with the ankle twist (front part of foot twisted also at that time).

So do you suggest i should have xray of foot and ankle from some other hospital? also please name the x-ray test for this situation.

I was wondering could the tiredness feeling (don't want to move much) most of the time be due to hypothyroid ?

Cheers!

Well reading your answer I will say it is more likely lumber strain, I mentioned lumber strain with disk herniation as even with lumber strain there is a very slight amount of pinching or pressure on nerves as the vertebrae are under strain. In pure disk herniation I know it would be more nerve pain like sharp pain radiating to leg, tingling numbness, weakness in area supplied by nerve so are you having this. Probably reading your answer I think so no. But as far as treatment is concerned its the same for lumber strain or disk herniation as I mentioned, many doctors suggest to take ample bed rest in such a situation that recommendation is old, latest recommendation you can carry out all your normal activities other than lifting heavy weights. The x ray is called x ray lumber spine AP and lateral view.

The leg pain is worrying as description you are telling is more likely of decreased blood supply. But that I would say is due to prolonged sitting with improper posture as you say you are software engineer so you might be sitting on a computer desk so have a proper posture here it is on google specially see how they keep something under their legs like some choki, links:

https://www.google.com.pk/search?q=proper+posture+for+sitting+at+a+computer+desk&espv=2&biw=1024&bih=628&tbm=isch&tbo=u&source=univ&sa=X&ei=fA4XVaSyO8GyUpPSgqAI&ved=0CBoQsAQ

Now how to minimise this decreased blood supply after one to two hours of sitting at work take a small 5-10min. walk, move your legs while sitting. Have a bigger chair if its congested. What is your BMI if its high then its the main cause of lumber strain and also what is your age. Exercise if BMI is high. Take the treatment I have given like sleep on floor/flat bed, diclofenac 75 mg 2 times, and paracetamol+orphenadrine two times see if this helps if not get the xray and go to a good neurologist ones mentioned in my previous posts.

Hypothyroid signs and symptoms fatigue, weight gain, constipation, cold intolerance, hair are thin and brittle, some cases have goiter if due to iodine deficiency, if you are having them get TSH and Free T3 and Free T4, but do not think it is the case here I think this weakness tiredness may be related to stress, is the workload heavy these days?

[s55]

I have cleared all my steps only step 3 licensing part is remaining. I would be applying next year. Its easier for green card holders aka US residents to get a residency only if scores are good all exams first attempt and CV is strong. Even if you are not a resident all that determines your fate would be first of all scores then all exams first attempt and then electives, research publications/experience, observerships lastly also years since graduation. But still US residents have a slight edge.

Another appeal to all PW to prey for my exam and residency. Thanks alot.

One more thing s55 the scores I was saying, criteria for scores is same for all international medical graduates that is danger zone is anything below 230 in any step, but I have seen people match even at 210 the thing which matters then is the lower your scores the more you have to cover them up with brilliant electives, observerships and research, but even those with high scores do not relax get into any available opportunity for electives, observerships or research. US citizens have advantage as many research opportunities are available to them and those programmes that do not want to get in the mess of visa processing and its related stuff.

JazakALLAH brother.. May you pass Step 3 with flying colors and get residency in US.. ameen!

[nasirjavaid]

Well reading your answer I will say it is more likely lumber strain, I mentioned lumber strain with disk herniation as even with lumber strain there is a very slight amount of pinching or pressure on nerves as the vertebrae are under strain. In pure disk herniation I know it would be more nerve pain like sharp pain radiating to leg, tingling numbness, weakness in area supplied by nerve so are you having this. Probably reading your answer I think so no. But as far as treatment is concerned its the same for lumber strain or disk herniation as I mentioned, many doctors suggest to take ample bed rest in such a situation that recommendation is old, latest recommendation you can carry out all your normal activities other than lifting heavy weights. The x ray is called x ray lumber spine AP and lateral view.

The leg pain is worrying as description you are telling is more likely of decreased blood supply. But that I would say is due to prolonged sitting with improper posture as you say you are software engineer so you might be sitting on a computer desk so have a proper posture here it is on google specially see how they keep something under their legs like some choki, links:

https://www.google.com.pk/search?q=proper+posture+for+sitting+at+a+computer+desk&espv=2&biw=1024&bih=628&tbm=isch&tbo=u&source=univ&sa=X&ei=fA4XVaSyO8GyUpPSgqAI&ved=0CBoQsAQ

Now how to minimise this decreased blood supply after one to two hours of sitting at work take a small 5-10min. walk, move your legs while sitting. Have a bigger chair if its congested. What is your BMI if its high then its the main cause of lumber strain and also what is your age. Exercise if BMI is high. Take the treatment I have given like sleep on floor/flat bed, diclofenac 75 mg 2 times, and paracetamol+orphenadrine two times see if this helps if not get the xray and go to a good neurologist ones mentioned in my previous posts.

Hypothyroid signs and symptoms fatigue, weight gain, constipation, cold intolerance, hair are thin and brittle, some cases have goiter if due to iodine deficiency, if you are having them get TSH and Free T3 and Free T4, but do not think it is the case here I think this weakness tiredness may be related to stress, is the workload heavy these days?

Thank you brother, very detailed and informative reply. As you suggested treatment is same for both I will try with your suggestions of hard bed and medicines. Aah yes the posture is problem I try to sit like the posture you mentioned in link but after some time realize that i am unintentionally sitting like this

https://encrypted-tbn3.gstatic.com/images?q=tbn:ANd9GcRMFbaf0GFJVrOMO7XUZaCkICrPlZpKegjDoQgZaPEtvOLFkhiAHg

As per my last calculation I think my BMI is between 25 and 30 ... my weight is 75Kg and Height is 5.9. I will be 39 this june. I will be going with your prescription and if not feeling difference then will get tested what you suggested.

[Glioblastoma]

JazakALLAH brother.. May you pass Step 3 with flying colors and get residency in US.. ameen!

Thanks alot.

[Glioblastoma]

Thank you brother, very detailed and informative reply. As you suggested treatment is same for both I will try with your suggestions of hard bed and medicines. Aah yes the posture is problem I try to sit like the posture you mentioned in link but after some time realize that i am unintentionally sitting like this

https://encrypted-tbn3.gstatic.com/images?q=tbn:ANd9GcRMFbaf0GFJVrOMO7XUZaCkICrPlZpKegjDoQgZaPEtvOLFkhiAHg

As per my last calculation I think my BMI is between 25 and 30 ... my weight is 75Kg and Height is 5.9. I will be 39 this june. I will be going with your prescription and if not feeling difference then will get tested what you suggested.

BMI as per my calculations is at 25 on borderline. Try exercising, adapting the proper posture, try diclofenac and paracetamol+orphenadrine try to avoid tizanidine even though its the most powerful muscle relaxant but has many side effects. If pain is not unbearable then drop diclofenac only use nuberol forte(paracetamol+orphenadrine) as it has both properties of pain killer and muscle relaxant. Take this medicine only for two weeks and above treatment and then lets see.

[nasirjavaid]

BMI as per my calculations is at 25 on borderline. Try exercising, adapting the proper posture, try diclofenac and paracetamol+orphenadrine try to avoid tizanidine even though its the most powerful muscle relaxant but has many side effects. If pain is not unbearable then drop diclofenac only use nuberol forte(paracetamol+orphenadrine) as it has both properties of pain killer and muscle relaxant. Take this medicine only for two weeks and above treatment and then lets see.

Sorry for late as I posted reply already but somehow it disappeared :(.
, the pain on outer side of leg has disappeared automatically without even starting your prescribed method... I felt these kinds of pain in some other areas like knees and hip joints and they disappeared after some time. Some old people tell that k " ye hawa ka dard ha".
What this "hawa ka dard " is actually?
Now only ankle pain is left and it feels a bit swollen but avoiding bad sitting habit seems making it better.

[Glioblastoma]

Sorry for late as I posted reply already but somehow it disappeared :(.
, the pain on outer side of leg has disappeared automatically without even starting your prescribed method... I felt these kinds of pain in some other areas like knees and hip joints and they disappeared after some time. Some old people tell that k " ye hawa ka dard ha".
What this "hawa ka dard " is actually?
Now only ankle pain is left and it feels a bit swollen but avoiding bad sitting habit seems making it better.

Ok thats good if it has disappeared by itself so most probably it was musculoskeletal in nature. Do Not take any medicines just use the proper posture. Don't lift heavy weights. Don't know myself what is "hawa ka dard" better ask the people who are telling it what they mean by it. As doctors we are trained if any patient uses a terminology we do not understand we must ask him about the explanation rather than interpreting it ourselves.

[nasirjavaid]

Ok thats good if it has disappeared by itself so most probably it was musculoskeletal in nature. Do Not take any medicines just use the proper posture. Don't lift heavy weights. Don't know myself what is "hawa ka dard" better ask the people who are telling it what they mean by it. As doctors we are trained if any patient uses a terminology we do not understand we must ask him about the explanation rather than interpreting it ourselves.

Sure sir, this is the first thing i am going to do about asking what is "hawa ka dard" in body ... another thing which i want to ask is is it normal that if i sit down like in yoga style for some time then "legs sunn ho jati hain" ? could it be due to less sleep as I hardly sleep 5-5.30 hours.

[Glioblastoma]

Sure sir, this is the first thing i am going to do about asking what is "hawa ka dard" in body ... another thing which i want to ask is is it normal that if i sit down like in yoga style for some time then "legs sunn ho jati hain" ? could it be due to less sleep as I hardly sleep 5-5.30 hours.

Well it depends from person to person on long it takes for the legs to develop numbness in a particular position if you are not used to it then it can take a matter of minutes to develop, and if used to it the numbness does not develop upto 1/2 an hour but the main reason due to which it happens is the lack of blood supply, it doesn't mean you have a disease of any vessels or anything but that your body is not accustomed to it, your body will get used to a particular position and increase it blood supply after training, like it occurs in exercise that slowly your body after training can pick up greater amount of weight. NOT related to sleep at all. But 5hrs. of sleep is low sleep should be at least 6hrs. If not it can give rise to multiple medical conditions including serious ones like strokes, heart attacks read this article its explained beautifully here for non medical persons.

10 Surprising Effects of Lack of Sleep

[nasirjavaid]

Well it depends from person to person on long it takes for the legs to develop numbness in a particular position if you are not used to it then it can take a matter of minutes to develop, and if used to it the numbness does not develop upto 1/2 an hour but the main reason due to which it happens is the lack of blood supply, it doesn't mean you have a disease of any vessels or anything but that your body is not accustomed to it, your body will get used to a particular position and increase it blood supply after training, like it occurs in exercise that slowly your body after training can pick up greater amount of weight. NOT related to sleep at all. But 5hrs. of sleep is low sleep should be at least 6hrs. If not it can give rise to multiple medical conditions including serious ones like strokes, heart attacks read this article its explained beautifully here for non medical persons.

10 Surprising Effects of Lack of Sleep

thanks sir... so no major issue for now ... but yes sleep is less. Even now my eyes are demanding sleep but mind wont let them ..... have GNC melatonin 3mg at home so thinking to use them to set sleeping time near 11- 11:59pm

thank you again for so beautifully explaining entire thing.

[hash4u]

you guys can come in my office safari hospital Behria town near car chowk rawalpindi timing 9am to 2pm
regard dr omair aman khan

Thank u for taking good care of my mom (tooth extraction)

[nasirjavaid]

Hey docs... can you tell the difference b/w Clenial C and Clenial A and Ventolin solution?

My son has allery problem even by some docs its diagnosed as childhood asthma but I don't believe... One reasonable child specialist told that its related to childhood and will go away as soon as child turns 12-13 of age as at the age of 7-8 children's wind pipes are narrow.

So to cut short my son was hospitalized 2 years ago for 2 days due to sever allergy attack and was given infusion drips and nablized with clenial and ventoline etc... Today I again felt symptoms of unusual breathing (like jerks in chest and fast breathing) and got him nablized with Clenial C 1ml+NS 2ml. in late night will nablize him with ventoline 0.5m+NS.

I would like to ask if its ok to treat him with these or I should visit the same child specialist for further advise? He is also not feeling hungry.
@glioblastoma @invincible_doc
Thanks.

[Glioblastoma]

Well clenil has salbutamol and beclomethasone. Beclomethasone is a corticosteroid therefore will reduce the symptoms more than ventolin which is plain salbutamol. But corticosteroids take longer to work therefore always combined with salbutamol or similar agents. So in my opinion always start with ventolin if it doesnot improves move to clenil.

Now these attacks are not normal, yes may be related to allergies or some other cause like a recent respiratory infection. I haven't came across anything till now that suggests that children's airways expand as they get older, so that is totally wrong.

How to diagnose, well get a pulmonary function test done simple plain accurate test to diagnose asthma. A more accurate test is methacoline challenge test but rarely used as it requires a lot of expertise and good facilities. A CBC may also be able to tell you by doing differential counts showing increased number of eosinophils or another test is doing a IgE levels which may be increased.

The symptoms you are telling currently I am tilting towards a respiratory infection. You can use these drugs when your child has difficulty breathing but its only a symptomatic treatment because if its an infection then that is the cause and that must be treated. So does he have fever, sore throat, cough, two signs you already told decreased appetite and difficulty breathing.