Case 26 A case of 20year old male with c/o generalized weakness and difficulty in walking since a week

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


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

CASE PRESENTATION:

A 20year old male pt came with the 

1.c/o difficult in walking since 1 week

2.generalised weakness since 1 week

Pt was apparently asymptomatic 3 months back  then  pt presented with c/o difficulty in walking and generalized weakness  for which he went to a local hospital and was diagnosed with hypokalemia and was treated but was not completely resolved. Now pt presented with c/o weakness and difficulty in walking which were aggravated since a week which was insidious in onset and progressive associated with tingling sensation over b/l upper and lower limbs.h/o not able to sense the floor while walking f/b difficulty in holding slippers(cotton wool sensation +).h/o of difficult in getting up from sitting position,difficulty in climbing stairs .h/o not able to button and unbutton his shirt. Pt is able to mix food,comb hair,turn on bed ,get up from lying down position.

H/o nausea and vomiting since a week which was associated with food intake(food particles as contents),non bilious,non projectile,non blood stained.

H/o constipation since a week.

H/o burning micturition since 4 days and decreased water intake since a week.

H/o pedal edema for 2 days which was 7 days back 

H/o sob on exertion since 10 days.

NO h/o head trauma,giddiness,convulsions,chest pain,palpitations,cough,cold,haematuria.

PAST HISTORY: 

H/o similar complaints of generalized weakness 3 months ago with h/o buckling.He was diagnosed having hypokalemia and was treated in a local hospital. 

Not k/c/o DM,HTN,asthma,CKD,CHD,Thyroid anomalies 

Non alcoholic and non smoker.No other addictions 

HABITS: He was on mixed diet, appetite normal, constipation only on high protein diet 


GENERAL EXAMINATION: pt was conscious,coherent,cooperative and well oriented.

No pallor,Icterus,cyanosis,clubbing, lymphadenopathy,edema

Hypopigmented patches were noted over palmar and plantar aspects


VITALS:

Temp: Afebrile on presentation 

BP:130/30mmhg on presentation 

PULSE:82pm

RR:21cpm

Spo2:98% on RA

CNS :

Higher mental functions intact

SENSORY SYSTEM:intact

Rombergs test:positive (swaying towards right)

MOTOR SYSTEM 

Bulk : normal in b/l UL & LL

Tone : normal in b/l UL & LL

Power :

 B/l U/L : proximal -5/5 ; distal -5/5

B/l LL:proximal-4/5 ; distal-3/5

Hand grip-100% in both hands

Hand muscles-5/5

Reflexes :

superficial reflexes : 

Abdominal reflex: absent

Corneal + ; conjunctival reflex+


CRANIAL NERVES :INTACT 

Cerebellar :

Finger nose:+

Finger nose finger:+

Dysdiadokinesia-

Tandem walking-

GAIT:high stepping gait.




PER ABDOMEN:

Soft,non tender

Bowel sounds +


CVS:s1 s2 heard, no murmurs

RS:NVBS



0

INVESTIGATIONS:

Urinary electrolytes 

Na+ :216

K+ : 98

Cl- : 355

Ecg: normal 



 7

PROVISIONAL DIAGNOSIS: 
PERIPHERAL NEUROPATHY 
?CIDP
WITH VITILIGO ; INDIRECT HYPERBILIRUBINEMIA

 TREATMENT 
1.INJ.OPTINEURON 1 amp in 500ML NS OD/iv
2.INJ.PAN40MG OD/IV
3.GRBS 8TH HRLY MONITORING 
4.BP 4TH HRLY MONITORING 
5.I/O CHARTING 

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