23 year old with weakness

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Here is the case i seen 

A 23year old man who is a student doing his degree 3rd year came to the hospital at night with cheif complaints of weakness in left sided upper and lower limbs since that day evening which is associated with deviation of mouth to right and involuntary movements of right lower limb.

He was apparently asymptomatic 11months back . Since then he has 4 episodes of left sided weakness as follows:-

Episode 1:-

He felt tingling sensation in his left upper and lower limbs which intially started  suddenly in left arm and progressed to entire limb followed by tingling in left lower limb when he was getting up after eating . He felt black outs along with tingling in his left upper and lower limb for 5 minutes . The black outs decreased after he took rest for 5 minutes. Tingling lasted for 10-15minutes.

     Meanwhile he had trauma to his right parietal bone 9months back due to hit to wall. After which there was a swelling . He did not visit a doctor and took home remedies. The event was not associated with any blurring of vision, vomitings, headache,seizures.

 

Episode 2:-

This occured 6months back. He felt the same tingling sensation in his left upper and lower limbs at around 4.30pm. Episode lasted for 15 minutes which releived on rest.

Episode 3:-

This occured 4months back . He complained the same features but of increased severity. Episode lasted for 10-15minutes and releived on taking rest.

Episode 4:-

This occured on the presenting day.while he was at his home. He was talking in his phone when the patient experienced a sudden onset on tingling sensation in his left upper limb which was severe progressed proximal to distal . Then he lost his grip on his phone and weakness in his left upper limb. This sensation progressed rapidly to left lower limb and the patient could not bear his weight on his left lower limb. By the time his mother approached him he was walking towards her dragging his left lower limb and taking support with his right hand. She also observed deviation of his mouth to right side which was not associated with any drooling of saliva. He also had slurred speech which became normal.

This episode is also associated with black outs and mild headache.

H/o headache on and off which was bilateral, mild, releived after drinking tea.

Then they went to a hospital  where some investigations were  done . Those investigations showed low K+ levels for which he was given SYRUP.POTASSIUM CHLORIDE. From there he got referred to our hospital for furthur management.

 When the patient presented here he was conscious coherent and cooperative. He has left upper and lower limb weakness associated with involuntary movements of right lower limb. Deviation of mouth to right side.

No h/o nausea, vomitings, loss of consciousness.

 He complained of pains in his right lower limb which were severe and spasmodic.

Vitals:- 

Afebrile., BP-120/80mm hg .,PR:-78bpm., RR-18cpm , SpO2 :- 99% at room air, GRBS:- 90gm/dl ., 

CVS:- S1 S2 +, no murmurs

RS:- BAE+, NVBS+, no added sounds

P/A :- soft, non tender, no organomegaly

CNS:-

HMF- normal

MOTOR SYSTEM:-

Bulk, tone are normal 

Reflexes:-     

                     Rt       Lt

Biceps         --         --  

Triceps        +        --

Knee           --          --

Ankle         +         --

Plantar      mute  mute

 INVESTIGATIONS:-

SErum electolytes-

Na+138meq/L., K+--3.8meq/L., Cl- 102meq/L

TREATMENT:-

1.IVF   1 DNS wuth 1 ampoule Optineuron @75ml/hr

2.INJ. ZOFER 4MG iv BD 15minutes before injection TRAMADOL

3.INJ.TRAMADOL 100mg IV BD

4. INJ.PANTOP 40MG IV OD

5. INJ.LORAZEPAM 2CC IV SOS

DAY 2:-

- no fresh complaints

-CNS EXAMINATION:-

BICEPS       absent both

TEICEPS     absent both

SUPINATOR     absent both 

KNEE      exaggerated on left absent on rt

ANKLE     exaggerated on left absent on rt

PLANTAR     flexion

INVESTIGATIONS:-

1.RFT

2.LFT

3.ECG

4.CBP

DAY 3:-

- patient is subjectively feeling better. He is able to raise his left upper limb above head  but a feel of slight heavyness and he is able to walk. 

CNS :-

HMF- NORMAL

MOTOR SYSTEM:-

Bulk, tone - normal

Power -5/5 in both UL AND LL

REflexes

                       Rt               Lt               

Biceps          -                   --

Triceps        --                   --

Supinator   --                   --

KNee          +++               +++

Ankle           ++                 ++

Plantar     decreased   mute

                    Flexion

Abdomial  --absent

INVESTIGATIONS:'

MRI BRAIN:-

TREATMENT:-

1.INJ OPTONEUROM 1AMPOULE IN 100ML NS IV BD

2. TAB.NEXITO PLUS PO H/S

3. TAB.CLONAZEPAM 0.25MG OD PO

4.TAB.SODIUM VALPROATE 200MG PO BD

FRESH ORDERS AFTER MRI ARE:-

1.  TAB.ECOSPIRIN  75MG PO OD

2. TAB. CLOPIDOGREL 75MG PO OD

3. TAB.ATORVASTATIN 20mg H/S

4.TAB.SODIUM VALPROATE 200mg PO BD

5.TAB.CLONAZEPAM 0.25mg PO OD

6. TAB.NEXITO PLUS H/S

2.FLP

DAY 4 :-

-NO fresh complaints

- the patient is feeling subjectively better

2D ECHO DONE

- TREATMENT:-

1.  TAB.ECOSPIRIN  75MG PO OD

2. TAB. CLOPIDOGREL 75MG PO OD

3. TAB.ATORVASTATIN 20mg H/S

4.TAB.SODIUM VALPROATE 200mg PO BD

5.TAB.CLONAZEPAM 0.25mg PO OD

6. TAB.NEXITO PLUS H/S