55yr old male patient with Hypokalemia associated with weakness for evaluation.

 THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

THIS E BLOG ALSO REFLECTS MY PATIENT CENTERED ONLINE LEARNING PORTFOLIO AND YOUR VALUABLE INPUTS ON THE COMMENT BOX IS WELCOME

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. 

A 55year old male came from kurmarthi , came to casualty with the complain of inability to lift his legs.

COMPLAINTS AND DURATION:-

The 55yr old male patient was apparently asymptomatic 7years back, one fine day he noticed difficulty in moving his left upper and lower limb, deviation of his mouth to right, and was side taken to hospital and diagnosed as left hemiplegia and treated after ,which the patient had recovered completely except for some movement restrictions in the left upper and lower limb, The symptoms lasted for about 2-3 weeks before recovery. Now the patient is complaining weakness in the both the lower limbs and the right upper limb ,since day before yesterday night 8pm.

The patient was symptom free after first onset,till day before evening.

HISTORY OF PRESENT ILLNESS:-

The patient is complaining of weakness in both the lower limbs as well as upper limbs and there was difficulty in holding the objects, raising the arm over head in the right upper limb and in the left upper limb,the patient had minimal movements

In the both lower limbs,there was weakness and difficulty to bear Weight, gripping of footwear.

The patient complains of difficulty in breathing even on rest .

No orthopnea,No H/o fever,No H/o bladder and bowel movement

HISTORY OF PAST ILLNESS:-

H/o of CVA in the past, 7yrs back which the patient had undergone treatment and recovered , except for some residual movement restriction in left U/L limb.

No similar c/o in the past.

K/c/o DM type 2 since 7years and is on medication.

Personal history:-

Diet- Mixed.

Appetite :- Adequate.

Bowel and bladder movements:- Normal

Addictions :- No addictions. (Toddy occasionally)

Allergies :- No allergies.

 VITALS:-

Temperature:-97.6°C

Pulse rate:- 80/min

Respiration rate:-18/min 

BP:- 100/60 mm/Hg 

SpO2:- 99%

GRBS:- 235mg%  

INVESTIGATIONS:-

HEMOGRAM:-

ECG:-

PROVISIONAL DIAGNOSIS:-

Hypokalemic Periodic Paralysis

Rx:-

1.Inj KCl -2Amp IN-500m/

Ns over 4-5hrs

2. Inj Optineoron 1 Amp IN 

100 ml Ns IV/OD 

3.Inj Pantop 40mg IV/OD 

4.Inj Mixtard 200-×-150

Monitor vitals 

Monitor GRBS