30 years old male with tingling and numbness in upper limbs

 SAI CHARITHA REDDY M

ROLL 115

This is online E log book 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 series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.

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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 plan.

A 30 year old male came to general medicine ops 

Chief complaints: 

Involuntary movements of hands and tingling and numbness in upper limbs and abdomen since  1 day  

History of presenting illness : 

Patient was apparently asymptomatic 20 days back then 

He developed fever insidious in onset, gradually progressive, low grade , intermittent not associated with chills and rigors and relieved by medication

He has a history of 4-5 episodes of vomitings 5 days back. Watery, non bilious ,non projectile, with food particles as contents.

And had a history of visit to nagarkurnool and consumed food there and due to water change patient also had hoarseness of voice 

Relieved by medication (unknown)

No c/o pain abdomen, loose stools  

c/o burning micturition 2 days back, relieved now

H/o similar complaints in the past(7 years back) (hypokalemiac periodic paresis)

No h/o DM,HTN, asthma, epilepsy,cad, thyroid disorders 

He used to take alcohol occasionally for the past 10 years and stopped taking 1 month back

He takes tobacco once in 2 days for the past 10 years 

Patient is not  co operative to let me take clinic images of chest and abdomen


 

O/E 

Patient is conscious, coherent and cooperative well oriented to time ,place and person

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy,edema


Vitals:
BP - 100/70mm hg
PR- 86 bpm
RR- 16 cpm

CVS EXAMINATION:
S1,S2 heard no murmurs

RS EXAMINATION:
trachea central
NVBS +
BAE +

P/A EXAMINATION:
Soft, non-tender
Bowel sounds heard


CNS EXAMINATION:
Hyporeflexia (due to hypokalemia) is 

Investigations 

Day 1

Serum electrolytes

   Na - 139 mEq/L

   K -2.3 mEq/L

   Cl - 95 mEq/L

   Ca - 1.01 mmol/L

  Mg - 2.0

Urinary electrolytes

  Na- 162 

  K - 7.3 

  Cl - 123

Urine Ph - 7.0

              CBNAAT REPORT

              SERUM ELECTROLYTES

                ECG

               AFB

Consolidations in the left upper lobe 

B/L hilar shows normal in size 

Trachea  central in position 

Cardiac size is normal 

Right lung shows normal translucency 

TREATMENT:

1)Inj. Kcl 50 mEq in 500 ml NS / IV over 5 hours

2) Inj. Zofer 4mg iv/OD 

3)Inj. Pan 40 mg IV/OD

AMC-30 YR M

C/O PAIN ABDOMEN 

ON EXAMINATION:

PATIENT IS C/C/C

TEMP: 98 F

BP:100/70 mmHg

PR:86 BPM

RR: 16CPM

CVS:S1,S2 HEARD ,NO MURMURS 

RS:BAE+,NVBS, NO ADDED SOUNDS

P/A: SOFT, NON TENDER

CNS:

 TONE NORMAL IN ALL LIMBS

POWER 5/5 IN ALL LIMBS 

Diagnosis:

HYPOKALEMIA UNDER EVALUATION