A case of 20year old male with c/o generalized weakness and difficulty in walking since a week

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CASE PRESENTATION:

A 20year old male pt came with the 

1.c/o difficult in walking since 1 week

2.generalised weakness since 1 week

Pt was apparently asymptomatic 3 months back  then  pt presented with c/o difficulty in walking and generalized weakness  for which he went to a local hospital and was diagnosed with hypokalemia and was treated but was not completely resolved. Now pt presented with c/o weakness and difficulty in walking which were aggravated since a week which was insidious in onset and progressive associated with tingling sensation over b/l upper and lower limbs.h/o not able to sense the floor while walking f/b difficulty in holding slippers(cotton wool sensation +).h/o of difficult in getting up from sitting position,difficulty in climbing stairs .h/o not able to button and unbutton his shirt. Pt is able to mix food,comb hair,turn on bed ,get up from lying down position.

H/o nausea and vomiting since a week which was associated with food intake(food particles as contents),non bilious,non projectile,non blood stained.

H/o constipation since a week.

H/o burning micturition since 4 days and decreased water intake since a week.

H/o pedal edema for 2 days which was 7 days back 

H/o sob on exertion since 10 days.

NO h/o head trauma,giddiness,convulsions,chest pain,palpitations,cough,cold,haematuria.

PAST HISTORY: 

H/o similar complaints of generalized weakness 3 months ago with h/o buckling.He was diagnosed having hypokalemia and was treated in a local hospital. 

Not k/c/o DM,HTN,asthma,CKD,CHD,Thyroid anomalies 

Non alcoholic and non smoker.No other addictions 

HABITS: He was on mixed diet, appetite normal, constipation only on high protein diet 

GENERAL EXAMINATION: pt was conscious,coherent,cooperative and well oriented.

No pallor,Icterus,cyanosis,clubbing, lymphadenopathy,edema

Hypopigmented patches were noted over palmar and plantar aspects

VITALS:

Temp: Afebrile on presentation 

BP:130/30mmhg on presentation 

PULSE:82pm

RR:21cpm

Spo2:98% on RA

CNS :

Higher mental functions intact

SENSORY SYSTEM:intact

Rombergs test:positive (swaying towards right)

MOTOR SYSTEM 

Bulk : normal in b/l UL & LL

Tone : normal in b/l UL & LL

Power :

 B/l U/L : proximal -5/5 ; distal -5/5

B/l LL:proximal-4/5 ; distal-3/5

Hand grip-100% in both hands

Hand muscles-5/5

Reflexes :

superficial reflexes : 

Abdominal reflex: absent

Corneal + ; conjunctival reflex+

CRANIAL NERVES :INTACT 

Cerebellar :

Finger nose:+

Finger nose finger:+

Dysdiadokinesia-

Tandem walking-

GAIT:high stepping gait.

PER ABDOMEN:

Soft,non tender

Bowel sounds +

CVS:s1 s2 heard, no murmurs

RS:NVBS

0

INVESTIGATIONS:

Urinary electrolytes 

Na+ :216

K+ : 98

Cl- : 355

Ecg: normal 

7

PROVISIONAL DIAGNOSIS: 

PERIPHERAL NEUROPATHY 

?CIDP

WITH VITILIGO ; INDIRECT HYPERBILIRUBINEMIA

 TREATMENT 

1.INJ.OPTINEURON 1 amp in 500ML NS OD/iv

2.INJ.PAN40MG OD/IV

3.GRBS 8TH HRLY MONITORING 

4.BP 4TH HRLY MONITORING 

5.I/O CHARTING