BILATERAL LOWER LIMB WEAKNESS in an 18 year old Female

Introduction: This is an online E-log Entry Blog to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs. 

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

Here, a 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 : 

• Patient was apparently asymptomatic till September,2021.
• In August 2021, she delivered a baby boy. Since then she has been having gradual weakness in both her upper and lower limbs.
• 2 months back, patient experienced an episode of bilateral weakness in upper and lower limbs, and 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 patient 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 fasciculations, no tremors.
• 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 had food as content.

DD:

GBS

Myopathies

Hypokalemia

Traumatic neuritis

Meningitis/encephalitis

Poliomyelitis

Myasthenia 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 well oriented to time, place and person.
• She is thin built and moderately nourished.
• No signs of 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

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 

Dysdiadokinesia - 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 air 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 11-01-2022

• Sodium - 1.1
• Potassium - 2.9
• Chloride - 10

Provisional diagnosis :

Paraparesis secondary to hypokalemia

Treatment 

IVF NS,RL @75 ML/HR

INJ OPTINUERON 1 AMP IN 100 ML NS IV/O

INJ PANTOP 40 MG IN/O

INJ ZOFER 4 MG IN/TI

SYP POTCHLOR 15 ML IN GLASS OF WATER PO/TI

MONITOR VITALS 4 TH HOURLY

I/O CHARTING

VISIT PROFILE

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