4. O. D. P.
• Alright before going to sleep the night before,
and on waking up in the morning she noticed
5. Difficulty in using her left
upper limb
Numbness of her left
upper limb
On waking up in morning
Around 1.5 hours after waking upDifficulty in sitting
without support
Following the next 2 to 3 hoursDifficulty in using her right
upper limb and both lower
limbs
Difficulty in moving her neck
sideways and lifting head
That late night
6. • No C/O – Altered Sensorium / Convulsions /
Headache
• No C/O – Difficulty in vision and opening eyes
(double vision / diminished vision)
• No C/O – Tingling and numbness of face and
other parts of body
• No C/O – difficulty in chewing
• No C/O – Deviation of mouth to one side /
dribbling of saliva
• No C/O – Difficulty in swallowing or speaking
• No C/O – Neck pain / pain in any limb
• No C/O – Bladder disturbances
7. • No C/O – Diarrhoea / Vomitting / Cough /
Fever
• No C/O – Abdominal Pain / Muscle Pain
• No C/O – Rash marks all over body/ Multiple
Joint Pains
• No H/O Recent Vaccinations / head trauma /
Medication ingestion / Recent Travel
• No H/O – Insect/animal bites
8. • Past History :
– N/K/C/O – DM, HTN
– N/P/H/S/O – TB, Jaundice
• Family History : DM in mother x 5 years
• Personal History : NAD
• Vaccination & Immunization History: Patient is immunized
in childhood according to IAP schedule
• Menstrual History:
– Menopausal since 8 years
• Obstretic History:
– G4P5A0L4
9. HISTORY CONCLUSION
• So, at the end of history we have a 42 y/o F, with rapidly
progressive, near-symmetrical type of paralysis involving all four
limbs as well as truncal muscles without the involvement of cranial
nerves, higher functions or overt sensory symptoms and intact
bladder, most likely we are dealing with a case of lower motor
neuron type (LMN) of palsy. I would like to label the patient at this
stage as a case of Acute Flaccid Paralysis (AFP).
– Guillian-Barre Syndrome
– Occult Bites:
• Envenomous Snake Bites
• Tick Paralysis
– Inceptive episode of periodic paralysis
10. GENERAL EXAMINATION
– GC – Guarded
– TPR – N / 60 / Regular
– Bp – 110 / 70 mmHg
• Oral Cavity – Normal
• No pallor/ cyanosis / clubbing / icterus / pedal
edema/ lymphadenopathy
• Back & Spine – Normal
• No Rash / Bite Marks / Tick stuck to the skin
11. CENTRAL NERVOUS SYSTEM
• Patient is conscious, well cooperative, well
oriented to time, place and person
• Her recent as well as remote memory is intact
• Speech is normal
12. CRANIAL NERVES
• Olfactory: Normal
• Optic:
– Acuity of vision: Normal
– Field of vision: Normal
– Color vision: Normal
• Oculomotor, Trochlear and abducens:
– No Ptosis
– No Squint
– No enophthalmos or exophthalmos
– Normal movement of eyeballs in all directions
– No Nystagmus
– Pupils:
• PERRLA
13. • Trigeminal:
– Motor Function: No hindrance in movement of
muscles of mastication
– Sensations on face: Intact
– Corneal Reflex:
• Right: Present
• Left: Present
– Jaw Jerk: Present
• Facial:
– Intact frowning, bilaterally equal nasolabial folds,
no deviation of mouth to one side,
– Bell’s Sign: Negative
14. • Vestibulocochlear:
– Watch Test: Patient perceives the sound
– Rinne’s Test: AC > BC
– Weber’s Test: Bilaterally equal
• Glossopharyngeal and vagus:
– Soft palate movement: Intact
– Gag Reflex: Present
• Spinal Accessory:
– Power of sternocleidomastoid and trapezius: 5/5
• Hypoglossal:
– Centralized on protrusion
– No fasciculation noted
26. CEREBELLAR SIGNS
• Finger-Nose Test : Not elicitable
• Dysdiadokokinesia : Not elicitable
• Intention Tremor : Not elicitable
27. OTHER SYSTEM EXAMINATION
• CARDIOVASCULAR EXAMINATION:
– S1, S2 Normal
– No murmurs
• RESPIRATORY EXAMINATION:
– AEBE
– No crepitations / rhochi
• PER ABDOMEN EXAMINATION:
– Soft, non tender
– Liver, spleen – Not palpable
– Bowel sounds - Present
28. HISTORY & PE CONCLUSION
• So, at the end of history & PE, we have a 42 y/o F, with rapidly
progressive, near-symmetrical type of paralysis involving all four
limbs as well as truncal muscles without the involvement of cranial
nerves, higher functions or overt sensory symptoms and intact
bladder, with generalised hypotonia, reduced motor power and
diminished reflexes; without evidence of any rash, muscle
tenderness, visible bite marks or ticks, nor any subtle sensory
examination findings. This could most likely be a case of lower
motor neuron type (LMN) of palsy due to:
– Periodic Paralysis
– Atypical Presentation of Gullian-Barre Syndrome
29. INVESTIGATIONS
INVESTIGATION VALUE NORMAL VALUE
Hemoglobin 11.20 gm% 12.0 – 16.0 gm%
Total WBCs 7,800 / cu. mm 4,000 – 11,000 / cu/ mm
Platelets Adequate
ESR 48 mm / hr 2 – 20 mm / hr
30. BIOCHEMICAL
INVESTIGATION VALUE NORMAL VALUE
UREA 45 mg/dl 13 – 45 mg/dl
Bilirubin
Total 0.9 mg/dl 0.1 – 1.2 mg/dl
Direct 0.4 mg/dl 0 – 0.4 mg/dl
Indirect 0.5 mg/dl 0.1 – 0.8 mg/dl
SGPT (ALT) 20 U/L <40 U/L
SGOT (AST) 26 U/L < 37 U/L
Alkaline Phosphatase 182 IU/L 28 – 111 IU/L
Total Protein 7.3 gm/dl 6.0 – 8.0 gm/dl
Albumin 3.8 gm/dl 3.2 – 5.0 gm/dl
31. BIOCHEMISTRY
INVESTIGATION VALUE NORMAL VALUE
S. Creatinine 1.1 mg/dl 0.5 – 1.4 mg/dl
S. Sodium 136 mEq/L 135 – 150 mEq/L
S. Potassium 3.0 mEq/L 3.5 – 5.0 mEq/L
S. Calcium 8.6 mg/dl 8.6 – 10.6 mg/dl
S. Magnesium 2.0 mg/dl 1.7 – 2.5 mg/dl
32. URINE EXAMINATION
CHEMICAL EXAMINATION
Reaction 6.5
Specific Gravity 1.005
Protein Present, +1 (30 mg/dl)
Glucose Absent
Ketone Absent
Blood Present, +1
Urobilinogens Absent
Bile Salts Absent
Bile Pigments Absent
38. BLOOD GAS ANALYSIS (ABG)
TEST RESULT
REFERENCE RANGE
(Arterial)
pH 7.38 7.35 – 7.45
PCO2 15.7 mmHg 35.0 – 45.0
PO2 150 mmHg >80
O2 Sat 99.4 % 95.0 – 98.0
Base Excess (Be) -14.7 mmol/L (-2) – (+3)
cHCO3 (P) 9.1 mmol/L 22.0 – 26.00
ctCO2 (B) 8.7 mmol/L 23.00 – 27.00
39. INVESTIGATION RESULT NORMAL VALUE
Urinary Potassium
(Spot)
19.5 mEq/L 22 – 164 (For Female)
Urinary Sodium
(Spot)
25 mEq/L 15 – 237 (For Female)
INVESTIGATION RESULT NORMAL VALUE
24 hour URINE
POTASSIUM
11.64 mmol/L < 20 mmol/L
40. INVESTIGATION RESULT NORMAL VALUE
Free T3 1.94 pg/ml 2.0 – 4.43
Free T4 1.16 ng/ml 0.93 – 1.70
TSH 2.22 μIU/ml 0.27 – 4.20
THYROID FUNCTION TESTS
41. What we could not do !!!
• Urine Osmolality
• Trans Tubular Potassium Gradient (TTKG)
• Early and prompt Arterial Blood Gas Analysis
(ABG)
• Nerve Conduction Studies, including exercise
testing
43. USG – B/L ADRENAL & THRYOID
GLAND
• B/L suprarenal region appears clear
• Thyroid gland appears normal in size,
homogenous echo pattern and normal
vasularity… no e/o focal lesion
44. • X – Ray DL Spine – AP, Lateral
• X – Ray Cervical Spine – AP, Lateral
– NAD
45. What we did !!!
• Gave Basic & Supportive treatment to patient
– ICU Care
– BiPAP Support (Day 2 to ½ of Day 3)
• Corrected Serum Potassium
– Intravenous
– Oral
• When symptoms reduced sufficiently not to
debilitate the patient, discharged her with very
close follow up with
– Oral Potassium Supplements
– Tab. Acetazolamide (250 mg) QiD
46. STATUS AS OF NOW !!!
INVESTIGATION RESULT NORMAL RANGE
pH 7.46 7.35 – 7.45
pCO2 14.4 35.0 – 45.0
HCO3 16.7 22.0 – 26.0
sO2 98.7 %
ABG
INVESTIGATION RESULT NORMAL RANGE
Serum Potassium 1.45 mEq/L 3.5 – 5.5 mEq/L
VENOUS SAMPLE ANALYSIS
47. STATUS AS OF NOW !!!
INVESTIGATION RESULT NORMAL RANGE
Urine K 16.08
Urine K / Cr (Ratio) 4.92
Urine Creatinine 37.0 30 - 125
51. Our Plan now … …
• Supplement IV and oral potassium to bring it
as close to normal as possible
• Start with Thiazide diuretics.
• Investigate for the case of probable Renal
Tubular Acidosis as below:
– Serum Chloride levels
– Serum and Urinary Ammonium ions
– Urinary pCO2
– Urinary Bicarbonate ion