1801006093 CASE PRESENTATION
LONG CASE
CHIEF COMPLAINTS-
A 40 year old woman came to the OPD with the chief complaints of
Generalised body pains & weakness and difficulty in walking since 6 months
HISTORY OF PRESENTING COMPLAINTS -
The patient was apparently asymptomatic 3 years back then she developed weakness in left lower limb which is sudden in onset and gradually progressive in nature. She was taken to the local hospital where she was found to have low potassium levels and was subsequently treated by giving potassium supplements with which she recovered.
In November 2021 - She experienced a severe episode of weakness of both upper and lower limbs (unable to lift hands and legs) along with loss of consciousness and loss of speech for 2 days.She also has h/o decreased bowel movements.She was diagnosed to be hypokalemic and potassium supplementation given. She was kept on ventilatory support. One unit PRBC transfusion also done. She stayed in hospital for 5 days after which she was discharged.
May 2022 - Similar attack which is less severe. Again treated for hypokalemia and discharged in 3 days.
February 2023 - She presented with 2 episodes of vomitings which is non-projectile, non-bilious and stained with food particles along with similar complaints of weakness as past.
During the hospital stay, she noticed a swelling in parotid region on left side and dryness of mouth for which she was referred to dental where medication was given and the swelling subsided in 2 days.
A biopsy was taken from the lip.
There is also complaint of dryness of eyes with burning sensation and dry skin with no itching.
In March 2023 when she came for follow up she was sent to ophthalmology dept where symptomatic treatment was given and further evaluation was done. She was referred to orthopaedic dept where X-ray was adviced.
At present she has generalised body ache and weakness which is more in the lower limbs and difficulty in walking. She has difficulty in getting up from lying position.
No h/o fever, cough, numbness and tingling sensation, colours changes in skin, dental caries
PAST HISTORY -
Not a k/c/o HTN, DM, TB, asthma, epilepsy, CAD, CVA
DRUG HISTORY -
She was on anti-rheumatoid drugs for 3 years
On daily Potassium syrup(potklor) since 3 years
FAMILY HISTORY -
No significant family history
PERSONAL HISTORY -
She used to work as a daily wage labourer but stopped working since 3 years due to these attacks of paralysis.
Appetite - normal
Diet - mixed
Bowel & bladder habits - regular(with medication)
Sleep - adequate
Addictions - none
GENERAL PHYSICAL EXAMINATION-
The patient is conscious, coherent and cooperative and well-oriented to time, place and person.
She is moderately built and nourished.
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal edema.
VITALS(on admission)
Temperature - Afebrile
BP- 110/70 mm hg
PR - 88 bpm
RR - 18 cpm
GRBS - 97mg/dl
SPO2 - 96%
SYSTEMIC EXAMINATION -
CVS -
No visible pulsations, scars, engorged veins
No rise in jvp
Apex beat is felt at 5th intercostal space medial to mid clavicular line
S1,S2 heard
No murmurs.
CNS -
GCS - E4,V5,M6
Sensory system - intact
Motor system -
R L
Bulk N N
Tone N N
Power
UL shoulder 4/5 4/5
arm 5/5 5/5
forearm 5/5 5/5
LL hip 4/5 4/5
knee 4/5 4/5
ankle 5/5 5/5
Cranial nerves -
5th sensory - intact
motor - intact
7th motor - normal facial expressions
sensory -normal taste sensation
corneal & conjunctival reflex- present
secretomotor - decreased moistness of eyes, tongue , buccal mucosa
8th - intact
Finger nose in coordination - no
Heel knee in coordination - no
RESPIRATORY SYS -
Shape of chest is elliptical and b/l symmetrical
Trachea is central
Expansion of chest is symmetrical
Bilateral air entry - positive
Normal vesicular breath sounds heard
ABDOMEN -
On inspection - abdomen is flat & symmetrical
Umbilicus is central and inverted
No scars, sinuses & engorged veins seen
All 9 regions of abdomen are equally moving with respiration
On palpation - abdomen is soft and non tender
On percussion - no shifting dullness, no fluid thrill
On auscultation - normal bowel sounds are heard
PROVISIONAL DIAGNOSIS -
Recurrent hypokalemic paralysis secondary to distal RTA with biopsy proven Sjögren’s syndrome and RA?
INVESTIGATIONS -
1-2-23
Serum electrolytes:
Sodium:142 mmol/l
Potassium: 1.8 mmol/l
Chloride: 108 mmol/l
Serum calcium:9.8mg/dl
Serum creatinine:1.3mg/dl
Blood urea:29mg/dl
Urinary calcium:3mg/day
Spot urine sodium:6meq/l
Spot urinary potassium:12meq/l
13-3-23
Hb: 9.6 g/dl
ESR: 30mm/hr
Serum creatinine: 1.1mg/dl
Serum potassium: 4mmol/l
SGOT: 23IU/l
SGPT: 16IU/l
15-3-23
ESR: 36mm/h
Serum sodium: 139mmol/l
Serum potassium: 3.06mmol/l
Serum chloride: 114mmol/l
Serum C3: 114mg/dl
Serum C4: 63mg/dl
Serum creatinine: 0.99mg/dl
SGOT: 15IU/l
SGPT: 11IU/l
16-3-23
RBS: 122mg/dl
CRP: negative
ESR: 30mm/hr
Hb: 9.1mg/dl
TLC: 10,100
Serum calcium: 9.2mg/dl
Serum magnesium: 2.1mg/dl
RA Factor - positive - 48IU/ml
Biopsy report:
H and E stained section shows the presence of multiples lobules of minor salivary gland tissue consisting of normal appearing mucous acini with intralobular and interlobar ducts. The salivary gland tissue also shows the presence of multiple foci (25) of lymphocytic infiltrate, endothelial lined blood vessels and hemorrhagic areas Correlating with clinical features, the above histopathological features are suggestive of Sjögren’s syndrome
X-rays
TREATMENT PLAN -
Syrup POTKLOR 15ml po/TID
TAB PREGABA M 75mg
TAB PANTOP
TAB HCQ 200mg BD
TAB NODOSIS
TAB WYSOLONE 10mg OD
TAB NAPROXEN 250mg SOS
A 28 year old male came to the OPD with the chief complaint of blood in stools since 1.5 years and shortness of breath on exertion since 1 year.
He is not a k/c/o HTN, DM, TB, asthma, CAD, CVA and epilepsy
USG ABDOMEN -
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