1801006093 - LONG CASE

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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.

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.

Link for gait video - Gait

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