case of "45 year old diabetic with acute quadriparesis and dysphagia and squint"
Hello everyone.. I am sreeram , an intern posted in medicine department and one of the important terms of getting the internship completion is to complete my log book with my online log of what I learn during the course of my duties.
A 45yr old man , mirchi bajji shop owner by occupation hailing from miryalaguda had complaints of generalised body pains since 1week , which was shooting type and radiating all over back and neck pains . Pt also was complaining of bilateral feet and hands tingling .
Then he went to a near by RMP where he got treated with Inj. Voveron but his symptoms had not got resolved.
Then the pt. Consulted another doctor and got his CT Brain done outside which was normal and was prescribed medications .
.Pt visited by himself riding motorcycle to doctor previous day , although he had generalised lethargy and weakness..he was able to perform his activities .
Then next day around noon pt had sudden onset of weakness of bilateral upper and lower limbs , associated with swaying and giddiness.
He has difficulty in standing , walking with instability and has to take support of his attenders while getting down from bed.,, while walking ,so next day pt reported to our hospital
With complaints of bilateral UL and LL weakness since 1day and severe shoulder and neck pains .
Pt also gives
H/o difficulty in buttoning and unbuttoning
H/o difficulty in mixing food., holding objects,cell phone , standing and walking, difficulty in climbing stairs, difficulty in standing from sitting position, giddiness while washing face, loss of appetite,
h/o difficulty in getting up from lying down,lifting head off from pillow,slippage of chappals present.
History of difficulty in roll over bed present .
H/o tingling and numbness in all limbs in stock and glove pattern .
Also gives h/ o double vision present on down gaze.
Inability to abduct left eye.
No h/o loss of consciousness, seizures, blurring if vision, head trauma, spine injury , fever, shortness of breath, dry cough, outside food intake. No travel history .
No h/o loss of smell, blurring of vision ,taste loss, loss of sensations over face, hearing loss , tongue deviation, difficulty in swallowing,difficulty in speech,hoarseness of voice,no difficulty in breathing ,
involuntary movements ,fasiculations ,twitching,
No sensory deficit in feeling clothes and hot or cold sensations.
No history of band like sensations
No history of cotton wool sensations ,no history of frequency ,urgency ,hesitancy , bowel and bladder incontinence
No history of sweating ,palpitations .
Next day after admission pt developed facial diplegia ,
Unable to close eye completely
Unable to blow cheecks ,unable to frown , .
Also was unable to celnch teeth .
No slurring of speech .
No drooling of saliva .
Following after 2 days also complained of difficulty in swallowing
PAST HISTORY:
He is a k/c/o HTN -- since 4 yrs., on regular medication of tab metoprolol succinate 50mg + tab amlodipine 5mg BD previously.
Presently using tab metoprolol 25mg+ telma 40mg BD.
DM -- since 4yrs, on regular medication of Metformin 500mg + glimiperide 2mg morning , Tenegliptin 20mg + Metformin 500mg evening.
No similar complaints in the past
surgical history: left eye cataract surgery 3months back.
FAMILY HISTORY-- patient mother was diabetic and hypertensive who was under medication .
Siblings also have history of hypertension.
No simliar past history and family history of weakness.
GENERAL EXAMINATION:
Obese , well nourished
afebrile ,
Pallor .,Icterus negative
No cyanosis,clubbing, lymphadenopathy,Edema.
no short neck
no scars;no h/o tropic ulcers
no neurocutaneous markers
Vitals : Bp 160/90 mmhg
Pr 80 bpm
SYSTEMIC EXAMINATION:
CVS :
s1 s2 hears no murmurs
RS :
bae + nvbs heard
P/A:
soft ,nontender, obese
CNS:
1)HMF:
patient conscious
oriented to place/time/person
no h/o aphasia/dysarthria
no h/o dysphonia
no h/o memory loss
no h/o emotional lability
2)CRANIAL NERVES-
CN6th : left abducent muscle paresis
CN7th : on 2nd day of pt hospital stay he developed facial diplegia. Unable to blow cheecks ,unable to frown ,Unable to close eye completely.
Cn 5th - unable to clench teeth .but facial sensations are intact .
Jaw jerk absent .
CN9th and 10 th :gag reflex is intact.
Rest of the cranial nerves were normal on examination.
Difficulty in swallowing complained after 2 days of admission .
3)MOTOR SYSTEM:
Right. Left
a)Bulk: normal normal
b)Tone: UL decreased decreased
LL decreased decreased
c)Power:
UL. Rt Lt
Supra and infraspinatus 4+/5 4+/5
Rhomboid 4+/5 4+/5
Serratus anterior 4+/5 4+/5
Pectoralis major 4+/5 4+/5
Lattissimus dorsi 4+/5 4+/5
Biceps brachi 4+/5 4+/5
Triceps 4+/5 4+/5
Brachioradialis 4+/5 4+/5
Ex Carpi radialis 4-/5 4-/5
Ex Carpi ulnaris 4-/5 4-/5
Flexor pollicis longus 4-/5 4-/5
Lumbrical and interrossei 4-/5 4-/5
LL. Rt Lt
iliopsoas 4+/5. 4+/5
adductor femoris 4+/5. 4+/5
gluteus medius 4+/5. 4+/5
gluteus maximus 4+/5 4+/5
hamstrings 4+/5. 4+/5
quadriceps femoris 4+/5. 4+/5
tibialis anterior. 4-/5. 4-/5
tibialis posterior. 4-/5. 4-/5
peroneii. 4-/5. 4-/5
gastronemius. 4-/5. 4-/5
ex digitorum longus. 4-/5. 4-/5
fx digitorum longus 4-/5. 4-/5
d)Reflexes.
Superficial reflexes
Right. Left
Corneal. P P
Conjunctival P. P
Abdominal. - -
Plantar - -
Deep tendon reflexes
Right. Left
Biceps. -- --
Triceps. --. --
Supinator. -- --
Knee -- --
Ankle. -- --
4)SENSORY SYSTEM
RIGHT. LEFT
Spinothalamic tract:
Anterior.
crude touch. N N
pain. N. N
temperature. N. N
Posterior.
fine touch. - -( over bilateral dorsum and plantar aspect of foot).
vibration. - -
position sense- impaired
Rhombergs - positive
- Cortical.
2 point discrimination N N
tactile localisation. N. N
5)CEREBELLUM.
Finger nose unable to perform .
Dysdiadokinesia + +
DIAGNOSIS : GBS(? AMSAN varient ) with progressive cranial nerve palsy
( Facial diplegia and left lateral rectus palsy ) .
CBP:
Hb -14.9g/dl
TLC-16700cells/cu.mm
Neutrophils 74%, Lymphocytes 15%,Eosinophils 03%,Basophils 00%,Monocytes 08%,Platelets- 2.91 lac cells/cu.mm.
FBS: 131mg/dl
CUE : normal
LIPID PROFILE:
Total cholesterol- 224mg/dl
Triglycerides- 171mg/dl
HDL-43mg/dl
LDL- 104mg/dl
VLDL- 34.2mg/dl
CSF biochemistry report:
No cells
protein - 47mg/dl
93mg/dl sugars
109mmol/lit chloride
TREATMENT :
TREATMENT :
Pt attenders were counselled adequately about his condition and course of disease in their own language and the difficulty in managing .
They were counselled about IVIG infusion and its outcomes ,Untill the attenders were thinking about it ,
Initially patient was started on
-INJ Optineuron inj 1amp in 100ml NS IV OD.
-Inj thaimine 100mg in 100ml NS iv BD
- INJ PAN 40mg po OD
- Tab metoprolol 25mg + telmisartan 40mg BD.
-Tab glimiperide M2 po OD at 8am
-Tab Tenegliptin 20mg + Metformin 500mg OD at 8pm
Tab Pregabalin -M 75 mg H/S
BP /PR/Rr/Spo2 charting 4th hrly
Single breath counting 4 th hrly.
GRBS charting 6th hrly.
Strict diabetic diet advised .
-Later when patient complained of difficulty in swallowing ..he was started on ryeles tube feeding .
And Human actrapid insulin according to GRBS .
REST same treatment continued .
On day 4 of admission , when pt attenders got IVIG , infusion was started at the rate of 0.4g/kg/day for 5 days .
His ideal body weight was 77 kg
So 30g/ day was planned to start .
Hoping for his revovery ..!
Thankyou .
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