A 45years old female with weakness in both upper and lower limbs

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This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent.

 Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident 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 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 45 YEAR OLD FEMALE WITH WEAKNESS IN BOTH UPPER AND BOTH LOWER LIMBS

CHIEF COMPLAINTS
 Excessive weakness and fatigue in both her legs and also her upper limbs since 4 days.
Loss of appetite and feeling of nausea when she tried eating since 4 days. 

HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 5 days back.4 days back, on Monday (29/05/23) 

She had an acute onset of weakness in her legs which started in the morning and gradually increased through the day. 

She also had no appetite.
 When she was forced to eat, she felt nauseous. 

She was able to do her normal household work despite the pain and weakness but... 
On Tuesday, ( 30/05/23) morning.. 
She tried walking despite her weakness but fell down and hit her head on the floor.

She has no history of and deviation of angle of mouth, blurring of vision, dribbling of water from mouth, numbness or tingling sensation. 

She has no history of slurring of speech, loss of consciousness, no bowel and bladder inconveniences. 

Her symptoms improved at the time of examination. 

DAILY ROUTINE OF THE PATIENT BEFORE ILLNESS :

She wakes up everyday, by 6am in the morning , freshens up and starts her day immediately with her work after a little bit of her daily chores( saree weaving). 
By 10am she has her breakfast and continues with her work again. 
Then takes a break for lunch around 1 am followed by a small nap. 
Then she resumes her work again till 8pm, has dinner, spends time with her family and then goes to sleep. 


HISTORY OF PAST ILLNESS
No history of similar complaints in the past
No h/o diabetes, hypertension, epilepsy, thyroid, asthma, TB

History of Renal calculi

SURGERY HISTORY

Patient underwent hysterectomy 2 months back. 
No history of blood transfusions

PERSONAL HISTORy

Married
Mixed diet
Adequate sleep till 5 days back. Couldn't sleep from monday due to pain
Loss of appetite since 4 days
Normal bladder
Normal bowel
No burning micturition
No addictions
No allergies

DRUG HISTORY

Took tablets for 4 weeks after her hysterectomy surgery. And then stopped( patient couldn't name the medicine or show us a sample) 

FAMILY HISTORY

no similar family history of weakness, fatigue and pain. 
No dm 
No htn
No thyroid
No asthma epilepsy tb cad

PHYSICAL EXAMINATION
Patient was 
Conscious, coherent and cooperative
Well oriented with time, space and person
Moderately built and nourished
Pallor - present
No icterus
No central cyanosis
No peripheral cyanosis
No clubbing 
No lymphadenopathy
No edema





VITALS
Bp - 108/95
Repiratory rate - 26 /min
Temperature - afebrile

SYSTEMIC EXAMINATION

CNS :

Patient is conscious
Speech - normal
No signs of meningeal irritation


CVS :

S1 and S2 heard
No murmurs

RS :

Normal vesicular breath sounds heard
No wheeze
No dyspnoea
Trachea - central in position

P/A :

Abdomen - scaphoid in shape
No scars, bruits, free fluid
Liver and spleen - not palpable
Bowel sounds heard





PROVISIONAL DIAGNOSIS

Quadriparesis under evaluation

TREATMENT
injection KCL 40 Meq in 500 ml normal saline
Injection Optineuron 1 ampule in 500 ml normal saline I. V O D
Monitor vitals


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