18 year old female with Bilateral lower limb weakness

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MUSKAAN GOYAL 

ROLL NO. 92

January 10th, 2021

Case:

18 year old female, house maker by occupation, resident of Masanpally, was brought to the OPD with chief complaints of 

• Bilateral  lower limb weakness since 1 day. 
• Fever since 1 day 

History of presenting illness : 

• Pateint was apparently asymptomatic till September,2021.
• In August 2021, she delivered a baby boy. Since then she has been having gradual weakness in both upper and  lower limbs.
• 2 months back, patient experienced an episode of bilateral weakness in upper and lower limbs, that the patient couldn't get up from the bed as soon as she woke up. She was immediately taken to near by hospital in Nalgonda, where she was diagnosed with weakness secondary to hypokalemia and was treated for the same in the hospital for 3 days. She regained the power and was discharged. She was adviced medications. The pateint took prescribed medication for 10 days and abruptly stopped the medication as she was feeling better.
• After stopping medication, patient experienced pain and weakness in the limbs which gradually increased. She presented to our hospital on 10th January,2021 with complaints of bilateral  lower limb weakness with dragging type of pain in upper limbs. She was not able to get up from the bed as soon as she woke up. She was able to roll on the bed but was unable to sit down or stand. Difficulty in lifting head off the pillow. No difficulty in respiration. No diurnal variation of weakness.
• No fasiculations, no tremors.
• No deviation of mouth, no slurring of speech.
• No sensory involvement and no bowel or bladder inconsistence.
• No abnormal movements of limbs.
• Patient experienced fever since 9th Jan in the evening. It was high grade and associated with chills and rigor. She was taken to an RMP and an injection was given.
• One episode of vomiting after admission in the hospital. It was non bilious, non projectile and food as content.

DD:

GBS

Myopathies

Hypokalemia

Traumatic neuritis

Meningitis/encephalitis

Poliomyelitis

Myesthenia gravis

Past history :

• Not a known case of Tb, asthma, epilepsy, HTN, DM, thyroid abnormalities.

Family history :

• Not significant.

Personal history :

• Diet - mixed
• Appetite - decreased since 5 months
• Sleep - adequate
• Bowel and bladder - normal
• No known allergies to drug and food
• No addictions
• Marital status - Married

Menstrual history :

• Menarche - 13years
• 6/30 cycle
• No clots, no dysmenorrhoea

Obstetric history :

• G1P1 - Male baby born at 7months of gestation with 1kg weight at birth by normal vaginal delivery.
• She did not breast feed the baby.

General examination :

• After taking consent, the pateint was examined in a well lit room.
• The patient is conscious, coherent, cooperative and we'll oriented to time, place and person.
• She is thin built and moderately nourished.
• No pallor, icterus, cyanosis, clubbing, lymphadenopathy, Edema, dehydration.

Vitals at the time of admission : 

• Temperature - Afebrile, measured in axilla.
• Pulse - 80bpm regular rhythm, normal in volume. No radio - radio or radio - femoral delay.
• Respiratory rate - 12cpm, regular, thoraco-abdominal.
• Blood pressure - 80/60 mmHg in left arm 
• SpO2 - 99% at room air.
• Grbs - 117mg% 

Systemic examination :

CNS examination -

HMF - intact

Cranial nerves - intact 

Motor system -.        Right.              Left 

Bulk -.                      Normal.         Normal

 on inspection and palpation.          

Power -           

Neck.                         Normal         normal

Upper limb.               5/5                  5/5

Lower limb.              3/5             3/5(on admission)

                                    4/5.             4/5 (presently)

Trunk muscles.      Normal.       Normal

Tone - 

Upper limb           normal.          Normal 

Lower limb.          Normal.         Normal

Reflexes-

Biceps.                     +.                       +

Triceps.                    +.                       +

Supinator.               +.                       +

Knee.                        +.                       +

Ankle.                       +.                       +

Plantar.                Flexor.             Flexor

Sensory system -

Pain - Normal 

Touch- fine touch - normal

             crude touch -  normal

Temp - normal

Vibration - normal

Joint position - normal 

Cerebellum

Finger nose test - normal 

Dysdiadocokinesia - normal 

Tandem walking - normal 

Rombergs test - normal

Gait - normal 

Signs of meningeal irritation - absent 

Autonomic nervous system - normal

Examination of other systems -

CVS - 

Inspection : no visible pulsation , no visible apex beat , no visible scars.

Palpation: all pulses felt , apex beat felt.

Percussion: heart borders normal.

Auscultation:S1, S2 Heard, no added murmurs.

      

Respiratory system -

Inspection: shape of chest : normal

Palpation: trachea normal, chest movement equal on both sides, vocal fremitus felt.

Percussion: resonant 

 Auscultation: Bilateral aur entry present, normal vesicular breathe sounds heard

Per abdomen - 

Inspection :  no engorged veins , no visible peristalsis

Palpation :soft, non tender, no organomegaly

Percussion: no free fluid.

Auscultation: bowel sounds heard

Investigations : 

1. Serum electrolytes 

2. Blood picture 

3. Urine analysis 

4. Urinary electrolytes 

5. USG 

6. ECG 

7. LFT 

8. ABG 

9. Echo

10. Serum Urea

Serum electrolytes - 

On 11-01-22

• Sodium - 1.1 
• Potassium - 2.9
• Chloride - 108

Provisional diagnosis :p

Paraparesis secondary to hypokalemia.

Treatment : 

IVF NS,RL @75 ML/HR 

INJ OPTINUERON 1 AMP IN 100 ML NS IV/OD 

INJ PANTOP 40 MG IN/OD 

INJ ZOFER 4 MG IN/TID 

SYP POTCHLOR 15 ML IN GLASS OF WATER PO/TID 

MONITOR VITALS 4 TH HOURLY 

I/O CHARTING