Long Case Final: 50 year old male with bilateral lower limb weakness
Neha Pradeep
K+: 2.7 mEq/L
04/06/22: 
05/06/22
3/6/22
4/6/22:
5/6/22:
Instruments:
Hall ticket: 1701006127
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I’ve 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.
CASE:
50 year old male patient with weakness of the lower limbs bilaterally since 2 days.
He is a resident of Nalgonda, and a daily wage worker till one year ago. He had a fainting episode after which he stopped going to work.
History of Presenting Illness:
Patient was apparently asymptomatic 4 months back when he developed pain in the right hip region, which was insidious in onset and intermittent at the beginning. Aggrevated on movement and relieved on rest and medication.
He went to the hospital 2 months ago when the pain progressed and became continuous, and was diagnosed with avascular necrosis of the femur due to a trauma to the hip one year ago.
2 days ago, patient developed weakness in the lower limb which progressed upto the hip.
The next morning, patient required assistance to walk and sit up but was able to feed himself. The weakness progressed so that by the evening he was unable to feed himself. He only responded if called to repeatedly.
The weakness was not associated with loss of consciousness, slurring of speech, drooping of mouth, seizures, tongue bite or frothing of mouth, difficulty in swallowing.
No complaints of any headache, vomitings, chest pain, palpitations and syncopal attacks.
No shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, abdominal pain or burning micturition.
Past History:
No similar episodes in the past.
Patient is a known case of diabetes since 12 years. He is on regular medication, with 15 U in the morning before breakfast and 10 U in the evening (7-7:30pm).
He was hospitalized, 4 years ago with low blood sugar, and was admitted for 10 days. He presented with altered mental status.
No history of hypertension, tuberculosis, epilepsy, asthma, thyroid and CAD.
No surgical history.
Personal History:
Diet: Mixed
Appetite: Normal
Sleep: Adequate
Bowel and Bladder: Regular bladder, decreased bowel
No allergies
Started alcohol intake 25 years back, and stopped 12 years when diagnosed with diabetes. He used to binge drink alcohol for 10 days continuously every month and then used to stop for 20 days. Cycle repeats every month. Now, consumed alcohol only on special occasions, doesn't exceed 90ml.
Started smoking beedis, one a day, 10 years ago.
Stopped 4 years ago when he went into a hypoglycemic episode, but has resumed one year ago.
Family History:
No similar history in family.
GENERAL EXAM:
Patient is examined in a well lit room after taking informed consent.
Patient is conscious, coherent and cooperative.
He is moderately built and moderately nourished.
Pallor: Present
Icterus: absent
Cyanosis: absent
Clubbing: absent
Generalized Lymphadenopathy: absent
Edema: Absent
Vitals:
Blood Pressure: 124/72 mmHg
Respiratory Rate: 17 cycles per minute
Pulse: 70 bpm
Temperature: Afebrile
Central Nervous System:
HIGHER MENTAL FUNCTIONS
• Conscious
• Oriented to person and place
• Memory : He was able to recognize his family members and recall recent events
• Speech: no deficit
CRANIAL NERVE EXAMINATION
• 1: Couldn't be elicited
• 2: Direct and indirect light reflex present
• 3,4,6: No ptosis or nystagmus
• 5: Corneal reflex present
• 7: No deviation of mouth, forehead wrinkling present and no loss of nasolabial folds.
• 8: Able to hear
• 9,10: Position of uvula is central, no deviation
• 11: Sternocleidomastoid contraction present
• 12: No tongue deviation
MOTOR SYSTEM:
Attitude - right lower limb flexed at knee joint
Tone - Normal on right side
Normal tone on left side
BULK: Right Left
Arm 22cm 22cm
Forearm 20.5cm 20.5cm
Thigh 34 cm 34 cm
Leg 26 cm 26 cm
TONE:
Right Left
• Upper limbs Normal Normal
• Lower limbs Normal Normal
POWER
Right Left
•Upper limb:
- Elbow: Flexor 5/5 5/5
Extensor 5/5 5/5
- Wrist: Flexor 5/5 5/5
Extensor 5/5 5/5
- Hand grip. 5/5 5/5
•Lower limb:
- Hip: Flexors 5/5 5/5
Extensors 5/5 5/5
- Knee: Flexors 5/5 5/5
Extensors 5/5 5/5
- Ankle-: DF 5/5 5/5
PF 5/5 5/5
- EHL: 5/5 5/5
- FHL: 5/5 5/5
REFLEXES
Right Left
Biceps 2+ 2+
Triceps. 2+ 2+
Supinator 2+ 2+
Knee 2+ 2+
Ankle 2+ 2+
Gait is normal
No involuntary movements
SENSORY SYSTEM
All sensations (pain, touch, temperature, position, vibration sense) are normal.
Cardiovascular System:
INSPECTION:
-Chest wall: bilaterally symmetrical
-Apical impulse and pulsations cannot be seen.
-No dilated veins, scars, sinuses.
PALPATION:
-Apical impulse is felt on the left 5th intercoastal space, 2cm lateral from the midline.
-No parasternal heave, thrills were felt.
PERCUSSION:
-Right and left heart borders percussed.
AUSCULTATION:
- S1 and S2 heard, no added thrills and murmurs heard.
Respiratory System:
INSPECTION:
-Chest is bilaterally symmetrical in shape and expansion.
-Trachea: Midline in position.
-Apical impulse is not appreciated
-Chest is moving normally with respiration.
-No dilated veins, scars, sinuses.
PALPATION:
-Trachea: midline in position.
-Chest is moving equally on respiration on both sides.
-Apical impulse is felt on the left 5th intercoastal space.
PERCUSSION:
The following areas were percussed on either sides-
1. Supraclavicular
2. Infraclavicular
3. Mammary
4. Axillary
5. Infraaxillary
6. Suprascapular
7. Infrascapular
8. Interscapular
All the above areas are resonant.
AUSCULTATION:
Normal vesicular breath sounds heard
No adventitious sounds heard.
Gastrointestinal System:
INSPECTION:
- Shape: Scaphoid
- Flanks: Free
- Umbilicus: central in position , inverted.
- All quadrants of abdomen are moving equally with respiration.
- No dilated veins, hernial orifices, sinuses
- No visible pulsations.
PALPATION:
- No local rise of temperature and tenderness
- All inspectory findings are confirmed.
- Deep palpation: no organomegaly was felt
- No guarding, rigidity
PERCUSSION:
- There is no fluid thrill or shifting dullness.
- Percussion over abdomen: tympanic note heard.
AUSCULTATION:
- Bowel sounds are heard.
PROVISIONAL DIAGNOSIS:
BILATERAL LOWER LIMB WEAKNESS DUE TO AN ENDOCRINAL OR METABOLIC CAUSE IN A PATIENT WITH DIABETES MELLITUS WITH A HISTORY OF AVASCULAR NECROSIS OF HEAD OF FEMUR.
GRBS
On day 1
4:30 pm - 272gm/dl
On day 2
8pm - 176mg/dl ( 8U HAI)
12pm- 205mg/dl
8am - 178 mg/dl ( 4 U HAI)
On day 3
12am - 120mg/dl
8am - 180mg/dl
2pm - 223mg/dl ( HAI 12 U)
On day 4
8pm- 203mg/dl
12 am - 210mg/dl
8 am - 302mg/dl
On day 5
8pm 478mg/dl
10pm- 325 mg/dl
2 am - 75mg/dl
8 am - 160mg/dl
Laboratory Investigations:
(03/06/22)
HEMOGRAM:
Hemoglobin: 8.6
TLC: 18380
N/L/E/M: 86/06/1/5
Platelet: 2.02
MCV: 71.6
MCH: 24.2
RDW: 15
PCV: 26.4
RBC COUNT: 3.63
ELECTROLYTES:
Na: 145 mEq/L
Cl: 110 mEq/L
K: 2.5 mEq/L
RENAL FUNCTION TESTS
Urea: 74
Creatinine: 3.7
Urine protein / creatinine: 0.27
Spot urine protein: 14.2 mg/ dl
Spot urine creatinine: 51.1mg/dl
LIVER FUNCTION TESTS
Total Bilirubin: 1.34
Direct Bilirubin: 0.55
SGOT:18
ALT:16
ALP:12.3
Total Protein: 6.3
Albumin: 3.16
A/G: 0.73
02/06/22:
03/06/22
K: 3.2 mEq/L
ECG:
2/6/22 (DOA):
ECG interpretation:
Inverted T waves were seen on day of admission
TREATMENT:
On day 1:
1) tab ecospirin 70mg OD
2) tab atorvas 10mg OD
3) inj NS, RL at 70ml/hr
4) syrup potchlor 15ml/po/tid
5) normal oral diet
6) inj HAI - TID
7) 2 amp KCL in 500ml NS slowly over 4-5 hrs
On day 2:
1) tab ecospirin 70mg OD
2) tab atorvas 10mg OD
3) inj NS, RL at 70ml/hr
4) syrup potchlor 15ml/po/tid
5) normal oral diet
6) inj HAI - TID
7) proteolytic enema
8) syrup cremaffine
9) tab spironolactone
On day 3:
1) tab ecospirin 70mg OD
2) tab atorvas 10mg OD
3) inj NS, RL at 70ml/hr
4) syrup potchlor 15ml/po/tid
5) normal oral diet
6) inj HAI - TID
7) proteolytic enema
8) syrup cremaffine plus 15ml/po/od
9) tab spironolactone 25mg/po/od
10) tab azithromycin 500mg OD
11) high protein diet
On day 4:
1) tab ecospirin 70mg OD
2) tab atorvas 10mg OD
3) inj NS, RL at 70ml/hr
4) syrup potchlor 15ml/po/tid
5) normal oral diet
6) inj HAI - TID
7) tab ultracet QID
8) syrup cremaffine plus 15ml/po/od
9) tab spironolactone 25mg/po/od
10) tab azithromycin 500mg OD
11) high protein diet
On day 5:
1) tab ecospirin 70mg OD
2) tab atorvas 10mg OD
3) inj NS, RL at 70ml/hr
4) syrup potchlor 15ml/po/tid
5) normal oral diet
6) inj HAI - TID
7) tab ultracet 1/2 po/ QID
8) syrup cremaffine plus 15ml/po/od
9) tab spironolactone 25mg/po/od
10) tab azithromycin 500mg OD
11) high protein diet
Medications:
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