50 year old male with weakness of both lower limbs and slurred speech

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 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 patients clinical problems with collective current based inputs.

CASE

 50 year old male with 

▪weakness of both lower limbs 

 and slurring of speech since 5 days

HISTORY  OF PRESENTING  ILLNESS

 Patient had a history of fall 1 year ago and he did not take any treatment for it and was alright for 8 months then 4 months back he had pain in right hip which was insidious in onset and gradually progressive in nature 

 since 1month there was change in the gait of patient which was noticed by his relatives and there is hematuria for 5 days which he has neglected

For which he consulted local doctor and diagnosed avascular necrosis of of femur for which he has given medication

After taking medication he developed weakness of both lower limbs but more on right side where he could not walk , stand and eat and he need assistance for these activities 

PAST HISTORY

 Known case of diabetes since 12 years and takes insulin daily 2 times ( 15 U before breakfast, 10 U in the evening)

not a known case of hypertension, asthma , TB, epilepsy

PERSONAL HISTORY

 Diet- mixed 

Appetite- normal 

Sleep - Adequate

Bowel and bladder movements- regular

Addiction- smoker since 12 years takes 1 beedi per day and stopped for 4 years and again started smoking  from 1 year

consumed alcohol nearly for 20 years and stopped taking it

 FAMILY HISTORY

 Insignificant

GENERAL EXAMINATION

 Patient is conscious coherent cooperative, well oriented to time place person

Moderately built and moderately nourished 

 Pallor- mild

icterus- absent

cyanosis- absent

clubbing- absent

Lymphadenopathy - absent

Edema- present

On 02/06/2022:

Bp - 120/80mmhg

PR - 92bpm

RR -17cpm

SpO2 -97%

GRBS - 150mg/dl

systemic examination

▪CVS-- s1 ,s2 heard no murmurs

• Respiratory system- normal vesicular breath sounds heard

 • Abdomen- no tenderness no. . palpable mass , not distended

On 03/06/2022:

c/c/c and afebrile

CVS - S1 S2+

CNS - Sensorium improved 

P/A - soft and non tender

On 04/06/2022:

c/c/c and afebrile

BP - 120/80mmhg

PR - 88bpm

CVS - S1 S2+

CNS - Sensorium improved 

On 05/06/2022:

c/c/c 

BP - 100/60mmhg

PR - 92bpm

CVS - S1 S2+

CNS - Sensorium improved 

R/S - BAE + and LT CREPTS +

P/A - soft and non tender.

On 07/06/2022:

BP - 120/80mmhg

PR - 92bpm

 Atrophy of right calf region 

sensations of both limbs - intact

absence of mobility of both limbs 





Provisional Diagnosis:

Hypokalemic periodic paralysis

INVESTIGATIONS

 29/5 /2022

  


2/06/ 2022






o










3/06/2022
 








USG

Rt kidney - 8.8 * 4.2 cm 

Lt kidney - 10*3.6 cm 

Size is normal but increased echotexture

CMD - partially maintained

Spleen - 12.9cm (increased)

Multiple intraductal and parenchymal calcification noted in pancreas involving and head and pancreas.

8mm calculus noted in inferior pole of left kidney.

Distended gall bladder with calcification noted of 6mm.


IMPRESSIONS ON USG

 • Cholelithiasis with GB sludge

 • chronic pancretitis

 • left renal calculus

 • mild



splenomegaly

 • B/L grade - II RPD changes

 • minimal ascitis

4/06/2022


5/06/2022




ECG Reports:

On 02/06/2022



On 06/06/2022:


TREATMENT

IVF RL NS @ 75ml/hr
Inj HAI s/C TIDaccording to sliding
Tab Azithromycin 500 mg po/ od
Tab ecosprin 75 mg PO/ OD
Tab atorvas10 mg 
syp pot chlor  15 ml
syp cremaffion
Tab spironolactone25 mg
high protein diet
Tab ultraset





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