Case History
A 45 year old female patient came with weakness of all four limbs, difficulty in walking since afternoon.
Predominantly lower limbs more than upper limbs, bilaterally symmetrical.
She was walking from the post office to her house where she suddenly felt weakness in her lower limbs which caused her to stop and sit down on her way. After which she couldn’t get up and had to be carried, there was no loss of consciousness.
She has no history of trauma, ear bleed, vomiting, loose stools, fever, pain abdomen, cough, chest pain, shortness of breath, palpitations, orthopnea, PND, no band like sensation, no pins or needle like sensation.
Stools passed today morning
History of similar episode 2 years back during summer which became alright after 2 days.
Family history: Similar episodes seen in a few members of her family, but of varying intensity.
On general examination:
Pallor is absent
Icterus is absent
No cyanosis
No clubbing
No lymphadenopathy
Dehydration is present
Temp- Afebrile
BP- 110/80mmHg
PR- 94 Beats per minute
CVS- S1 S2 heard, no murmurs
RS- BAE+ NVBS
P/A- Soft, non tender
CNS
Speech: Normal
Cranial nerves: Intact
Sensory system: Intact
Motor System:
POWER
|
Right
|
Left
|
Upper Limb
|
4/5
|
4/5
|
Lower Limb
|
2/5
|
2/5
|
TONE
|
Right
|
Left
|
Upper Limb
|
Decreased
|
Decreased
|
Lower Limb
|
Decreased
|
Decreased
|
REFLEXES
|
Right
|
Left
|
Biceps
|
+
|
+
|
Triceps
|
+
|
+
|
Supinator
|
+
|
+
|
Knee
|
-
|
-
|
Ankle
|
-
|
-
|
Plantar
|
Mute
|
Mute
|
No cerebellar signs.
INVESTIGATIONS
RFT:
Showed a decrease in the potassium levels of the patient
Urinary electrolytes:
Showed lower than normal excretion of K+ which excludes any renal cause.
ECG showing flattened T waves with prominent U waves- classic of Hypokalemia
Hemogram:
Reports do not show any anomaly
CUE:
Shows increased sugars in urine.
The patient was given an infusion of 2 ampoules of KCl in 500ml of NS immediately. Her other treatment comprised of an
Inj. PAN 40mg intravenously, once a day
Syrup Potcholor 20mg, orally, thrice a day, in half glass of water
Blood pressure, respiratory rate, pulse rate was monitored ever hourly
GRBS charting was done every 6 hours
Strict intake output charting was maintained.
Diagnosis- Hypokalemic Periodic Paralysis
The next day- Patient moderately improved and her serum potassium levels were 2.7mmol/L after one correction.
On general examination:
Dehydration is not present
Temp- Afebrile
BP- 120/80mmHg
PR- 90 Beats per minute
CVS- S1 S2 heard, no murmurs
RS- BAE+ NVBS
P/A- Soft, non tender
CNS
Speech: Normal
Cranial nerves: Intact
Sensory system: Intact
Motor System:
POWER
|
Right
|
Left
|
Upper Limb
|
4/5
|
4/5
|
Lower Limb
|
2/5
|
2/5
|
TONE
|
Right
|
Left
|
Upper Limb
|
Improved
|
Improved
|
Lower Limb
|
Decreased
|
Decreased
|
REFLEXES
|
Right
|
Left
|
Biceps
|
+
|
+
|
Triceps
|
+
|
+
|
Supinator
|
+
|
+
|
Knee
|
-
|
-
|
Ankle
|
-
|
-
|
Plantar
|
Muted
|
Muted
|
Biceps:
Triceps:
Supinator:
Knee:
Ankle:
Plantar:
No cerebellar signs.
INVESTIGATIONS:
Serum potassium after 1st correction was 2.7mmol/L
Her ECG after the first correction
Investigations were performed to determine her sugar level.
FBS:
Showed values greater than normal
Glycosylated haemoglobin: showed that she was a diabetic.
Post-prandial Blood Sugar: Levels were elevated.
Thyroid Profile: Turned out to be normal
The patient was given an infusion of 2 ampoules of KCl in 500ml of NS to further correct her potassium levels and was given oral hypoglycaemics for the correction of her blood sugar levels.
Tablet Glimiperide 0.5mg, once a day.
Tablet Metformin 500mg, twice a day.
Blood pressure, respiratory rate, pulse rate was monitored ever hourly
GRBS charting was done every 6 hours
Strict intake output charting.
The next day:
The patient subjectively improved, and she was able to walk on her own and her potassium levels were 3.9mmol/L.
On general examination:
Dehydration is absent
Temp- Afebrile
BP- 110/70mmHg
PR- 86 Beats per minute
CVS- S1 S2 heard, no murmurs
RS- BAE+ NVBS
P/A- Soft, non tender
CNS
Speech: Normal
Cranial nerves: Intact
Sensory system: Intact
Motor System:
POWER
|
Right
|
Left
|
Upper Limb
|
4/5
|
4/5
|
Lower Limb
|
4/5
|
4/5
|
TONE
|
Right
|
Left
|
Upper Limb
|
Normal
|
Normal
|
Lower Limb
|
Normal
|
Normal
|
REFLEXES
|
Right
|
Left
|
Biceps
|
++
|
++
|
Triceps
|
++
|
++
|
Supinator
|
++
|
++
|
Knee
|
+
|
+
|
Ankle
|
-
|
-
|
Plantar
|
Flexor
|
Flexor
|
INVESTIGATIONS:
Serum potassium on this day was 3.7mmol/L
USG: Patient was taken for an ultrasound abdomen to rule out the presence of any adrenal masses.
Which revealed grade II fatty liver and cholelithiasis (Multiple calculi in the gall bladder largest measuring 7-8mm)
Incidental finding of a hypoechoic lesion measuring 1.7*0.7cm in the posterior myometrium was found.
Gynaec referral was done in view of pain in the left flank left, non-radiating and the USG showing a hypoechoeic lesion in posterior myometrium.
A per speculum examination revealed: A polypoidal growth of 1*1cm through central os from 2’O clock position
Vagina is healthy
Uterine size cannot be assessed.
P2L2 with post myometrial fibroid(?) or endometrial polyp(?)
And was advised: No active gynaecological intervention needed as patient is asymptomatic.
TREATMENT:
Tablet Glimiperide 0.5mg, orally, once a day.
Tablet Metformin 500mg, orally, thrice a day.
Monitoring of blood pressure, respiratory rate and pulse rate.
Strict I/O charting.
GRBS charting every 6th hourly.
Tablet Ultracet 1/2tablet, orally, upto four times a day.
The patient’s dose of oral hypoglycaemics was titrated and she was counselled on the importance of a potassium rich diet compatible with hyperglycaemia.
Here is an article talking about hypokalemia with low renal loss of potassium.
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