A 70 year old male presented to opd with chief complaints of weakness in both upper limb and lower limb
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I have been given this case to solve 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.
A 70 year old male presented to opd with chief complaints of weakness in both upper limb and lower limb Since 1/2/23 evening
Slurring of speech since 1/2/23 evening
Patient was apparently asymptomatic till yesterday then he started having pain in both lower limb followed by weakness in both upper limb and lower limb and slurring of speech
No C/o chest pain,palpitations,sob
No c/o orthopnea,PND
H/o thorn prick to left LL followed by cellulitis of left ll for which fasciotomy was done 1.year back
Past history- Not a K/c/o
Htn, DM, TB, Epilepsy,Asthma
GENERAL EXAMINATION:-
THE PATIENT IS CONSCIOUS COHERENT AND COOPERATIVE
NO PALLOR ; ICTERUS; CLUBBING; CYANOSIS; ODEMA ; LYMPHADENOPATHY
TEMPERATURE:- 98.8 F
PR:92 bpm
BP:140/100 mm Hg
RR-16 cpm
Grbs- 132 mg/dl
SYSTEMATIC EXAMINATIONS:-
CNS Examination:
Higher mental functions:
Patient is conscious oriented to time place and person
Speech and language :slurring of speech present
Memory :intact( Recent,Immediate,Remote)
Hallucinations -absent
Sensory system - Normal
Motor system- Right. Left.
Tone- Upper limb Hypo Hypo
Lower limb Hypo Hypo
Power- Upper limb 2/5 2/5
Lower limb 2/5 2/5
Reflexes- Biceps. Absent Absent
Triceps 2 + 2+
Supinator. Absent Absent
Knee 2+ 2+
Ankle. 1+. 1+
Plantar Mute Mute
CVS:S1 S2+,NO MURMURS
RS:BAE+ ; NVBS
P/A:SOFT ; NON TENDER ; NO ORGANOMEGALY
Provisional diagnosis-
Quadriparesis secondary to hypokalemia
Investigations-
2/9/23
Hemogram
Hb- 19.3
TLC - 25,900
PLT count- 2.95
PCV - 55.1
Mcv - 83.9
Mch- 29.4
CUE-
Sugars - nil
Alb - 3-4
Pus cells - 3-4
Epithelial cells - 2-3
RFT-
Blood urea - 53
S.creat- 1.7
Na+ 130
K+ # 2.6
Cl - 100
S. Magnesium- 1.9
LFT -
Tb- 2.25
Db - 0.48
Sgot- 29
Sgpt- 16
ALP - 211
TP - 7.7
Alb - 1.16
ABG
PH - 7.351
3/9/23
Hb - 16.4
Tlc- 20000
DLC - 2.27
Rft
S. Na + 132
S. K+ 2.7
S. Cl - 106
4/9/23
Na+ 136
K+ 1.8
Ca+ 104
4/9/23
S -
C/o weakness in both upper and lower limb,
C/o slurring of speech
O -
Hypokalemic periodic paralysis denovo htn
A: On examination
Patient is conscious coherent and cooperative.
No Pallor, Icterus, cyanosis, clubbing, lymphadenopathy, edema.
Vitals:
Temp: 98.6 F
PR: 72 bpm
BP:120 /80 mm hg
RR: 25 cpm
CVS: S1 ,S2 heard
RS:B/L AE present , NVBS +. No added sounds
P/A:Soft, non tender, no organomegaly.
No rigidity,Guarding.
CNS: Rt Lt
Tone U/L Hyper Hyper
L/L Normal Normal
Power- U/L 4-/5 4-/5
L/L 4-/5 4/5
Reflexes- B 3+ 3+
T 3+ 3+
S. 3+. 3+
Knee 3+ 3+
Ankle. 1+. 1+
Plantar Mute Mute
P:
1) IV NS @50 ml/hr
2) Syp. Potklor 15 ml in 1 glass of water PO/TID
3) T. ECOSPRIN -AV 75/10 Po/ Hs
4) Strict I/o charting
5)Monitor vitals every 2nd hrly
6)T.Telma 40 mg Po /OD
7)Inj. Ceftrioxone 1gm IV/ Bd
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