18 Y FEMALE WITH WEAKNESS IN LOWER LIMBS

Soumya Menda

3rd sem

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent.
 Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case in an attempt to understand the topic of  " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

Case scenario:

A 18 year old female came to causality on 8/7/21 with Cheif complaints of
  • Weakness in both lowerlimbs. 
  • Unable to stand and walk.  
History of present illness:





18 year old female ,a daily wage labour,

H/o Seizure episode and weakness of both lower limbs
Was unable to walk without support till 6 years of age
Faced difficulty in studying and writing at 6 years
Was able to do work at home by 8 years since then unable to do heavy work
At 15 years attained normal growth and normal milestones
2 months back developed sudden onset of oedema which relieved on rest.

One morning ,went for urination & Suddenly she is unable to get her on her own ,on visiting local hospital diagnosed with Hypokalemic periodic paralysis.

Then she took herbal medicine for 10 days and able to get on her own with support,and developed nausea ,vomiting 2-3 episodes ,then on visiting hospital diagnosed with Dyselectrolytemia.

Then developed spasm of upperlimbs and profuse sweating.
No H/o fever/cold/cough
No H/o head trauma
No H/o seizure episodes after 
No H/o chest pain,palpitations
No H/o abdominal pain and abdominal distension,
c/o abdominal pain squeezing type after consumption of food,relived after sometime on its own
No H/o outside food consumption
Outside MRI showing B/L Mild cerebellar & vermian atropy.

Treatment History:

Herbal medicine for 10 days

Personal History:
  • Occupation: Daily wage labour
  • Appetite: normal
  • Diet: mixed
  • Bowls: regular
  • Micturition:normal
  • No known allergies
  • No addictions.

Family History:

  • No H/o Diabetes,HTN,asthma,heart disease and other hereditary diseases.
Menstrual History:
  • Age of menarche : 12 year 
  • Menstrual cycle :3/30
  • And Regular

General examination:
  • O/E
  • Pallor: present
  • Icterus: absent
  • Cyanosis: absent
  • Clubbing of fingers:absent
  • Lymphadenopathy: absent
  • Oedema of feet: absent
      Vitals:
  • PR : 82 bpm
  • RR : 20 cpm
  • BP : 110/70 mmHg
  • Spo2 : 98% at room air

Systemic examination:


CNS:
  • Tone :
                               UL.                LL 
                 
                 Rt.        Normal.       Normal
              
                 Lt.         Normal.       Normal
               
  • Cerebellar signs: 
  1. Finger-nose in-coordination:No
  2. Knee-heel in-coordination : No  


Provisional diagnosis:

Hypokalemic periodic paralysis
 
 
Investigations:


No sonological Abnormalities detected




 Diagnosis:
 
Spastic paraperesis-secondary to perinatal insult
Peripheral neuropathy-Distal sensory motor
Hypokalemia is resolved by 10/7/21
 

Treatment plan:
On 8/7/21- 
  1. Inj.Optineuron 1 amp in 100 ml NS/IV
  2. Tab. Pregaba m 
  3. Tab. pcm 650 mg
  4. Tab.pan 40 mg.  
On 9/7/21-
  1. Inj. Optineuron 1 amp in 100 ml NS/IV
  2. Ivf. dns @75 ml/hr
  3. Tab.pcm 500mg /po/sos

                    On 10/07/21

O/E
  • Pt.-c/c/c
  • PR - 135 bpm
  • BP - 90/70 mmHg 
RS - Bilaterally air entry present and clear

CVS : S1 & S2 heard       
        
P/A : soft ,no organomegaly detected.

CNS:
     
  •  HMF - Intectual disability 

  • Motor-                Rt.                      Lt
  1. Tone.    UL           N                     N
                        LL.     Increased    Increase

      2. Power.   
                      UL.            4/5.               4/5
                
                      LL   prox. 4/5               4/5

                              Dist.   3/5               3/5

       3. Reflexes 
                     
                 Biceps              +1               +1

                 Triceps            +1                +1

                 Supinator        +1               +1

                 Knee                  -                    -

                 Ankle                 -                    -

                 Plantar              F                  F

          
  •  Sensory 
  1. Tem :                       +                    +             
  2. Touch                      +                    +                     
  3. Pain                          +                   +                         
  4. Vibration     UL.     +                   +                              LL        -                    -                
  5. Joint position                                                             UL       +                   +                                LL        -                   -
  •   Cerebellar signs     
                  Disadidokinesis
                  Finger- nose incoordination
                  Heel- knee test-
  •  Romberg's test positive
  • Gait -spastic 
Treatment:
  1. Inj. Optineuron 1 amp in 100 ml NS/IV
  2. Ivf. dns @75 ml/hr
  3. Tab.pcm 500mg /po/sos 
Further Investigations: 
          
     


 

On 11/7/21

      C/O - Dragging pain in both lower limbs

       O/E
  • Pt - c/c/c
  • PR - 128 bpm
  • BP - 110/70 mmHg
  • RR - 18 cpm
  • RS -  Bilateral air entry present and clear
  • CVS - S1 & S2 are heard           
  • A/p - soft
  • CNS - Left handedness
                   Intellectual disability present
            

Diagnosis state:

      Spastic paraperesis secondary to perinatal insult
       Peripheral neuropathy Distal >Proximal motor sensory
       Hypokalemic periodic paralysis

Treatment:
  
  1. Ivf - dns @75 ml/hr
  2. Syp.Potchior 10 ml in 1 glass of water/po/OD
  3. Inj.Optineuron 1 amp in 100ml NS/IV/OD
  4. Tab. Clonazepam 0.25mg/po/sos
PR/Temp/BP charting 4th hrly.


                       On 12/7/21


C/O - Dragging pain in both lower limbs

       O/E
  • Pt - c/c/c
  • Temp - 101 F
  • PR - 84 bpm
  • BP - 100/70 mmHg
  • RR - 18 cpm
  • RS -  Bilateral air entry present and clear
  • CVS - S1 & S2 are heard           
  • A/p - soft
  • CNS - Left handedness
                   Intellectual disability present

Investigative findings:      
   


Diagnosis state:

      Spastic paraperesis secondary to perinatal insult
       Peripheral neuropathy Distal >Proximal motor sensory
       Hypokalemic periodic paralysis

Treatment:

  1. Ivf - dns @75 ml/hr
  2. Syp.Potchior 10 ml in 1 glass of water/po/OD
  3. Inj.Optineuron 1 amp in 100ml NS/IV/OD
  4. Tab. Clonazepam 0.25mg/po/sos
PR/Temp/BP charting 4th hrly.


                        On 13/7/21

O/E
  • Pt - c/c/c
  • Temp - afebrile 
  • PR - 98 bpm
  • BP - 110/70 mmHg
  • RS -  Bilateral air entry present and clear
  • CVS - S1 & S2 are heard           
  • A/p - soft
  • CNS - Low HMF
                    Cranial nerves intact

                    Motor - 
  1. Tone :                   Rt.                Lt.                                  UL        n                  n
                          LL.  increased    increased
      
      2.Power: UL               4/5               4/5
                             
                        LL   prox.  4/5              4/5

                                Dist.   3/5               3/5
      3.Reflexes 
                     
                 Biceps              +1               +1

                 Triceps            +1                +1

                 Supinator        +1               +1

                 Knee                  -                    -

                 Ankle                 -                    -

                 Plantar              F                  F

                       
Diagnosis state:

  Spastic paraperesis secondary to perinatal             insult
        Hypokalemic paralysis        

Treatment:

  1. Inj.Optineuron 1 amp in 100ml NS/IV/OD
  2. Tab. Clonazepam 0.25mg/po/sos 
  3. PR Monitoring 6th hrly.

                        On 14/7/21

O/E
  • Pt - c/c/c
  • Temp - afebrile 
  • PR - 108 bpm
  • BP - 100/70 mmHg
  • RS -  Bilateral air entry present and clear
  • CVS - S1 & S2 are heard ,no murmurs     
  • CNS - Low HMF
                    Cranial nerves intact

                    Motor - 
  1. Tone :                   Rt.                Lt.                                  UL        n                  n
                          LL.  increased    increased
      
      2.Power: UL               4/5               4/5
                             
                        LL   prox.  4/5              4/5

                                Dist.   3/5               3/5
      3.Reflexes 
                     
                 Biceps              +2               +2

                 Triceps            +2                +2

                 Supinator        +1               +1

                 Knee                 +1               +1  

                 Ankle                +1               +1    

                 Plantar              F                  F

                       
Diagnosis state:

  Spastic paraperesis secondary to perinatal             insult
        Hypokalemic paralysis     

 1 episode of femur spike not associated with chills/rigor.
   
Treatment:
  1. Tab.MUT /po/OD
  2. Tab.PCM 500mg/po/sos
  3. Tab. Clonazepam 0.25mg/po/sos 
  4. PR Monitoring 6th hrly.
  5. Thrombophobe ontiment ROR E/A.

                     On 15/7/21

O/E
  • Pt - c/c/c
  • Temp - afebrile 
  • PR - 112 bpm
  • BP - 100/70 mmHg
  • RS -  Bilateral air entry present and clear
  • CVS - S1 & S2 are heard ,no murmurs     
  • CNS - Low HMF
                    Cranial nerves intact

                    Motor - 
  1. Tone :                   Rt.                Lt.                                  UL        n                  n
                          LL.  increased    increased
      
      2.Power: UL               4/5               4/5
                             
                        LL   prox.  3/5              3/5

                                Dist.   4/5               3/5
      3.Reflexes 
                     
                 Biceps              +2               +2

                 Triceps            +2                +2

                 Supinator        +1               +1

                 Knee                 +1               +1  

                 Ankle                +1               +1    

                 Plantar              F                  F

                       
Diagnosis state:

  Spastic paraperesis secondary to perinatal             insult
        Hypokalemic paralysis     

   
Treatment:
  1. Tab.MUT /po/OD
  2. Tab.PCM 500mg/po/sos
  3. Tab. Clonazepam 0.25mg/po/sos 
  4. PR Monitoring 6th hrly.
  5. Thrombophobe ontiment ROR E/A.

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