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Rtr-Internal Medicine: Case Presentation
Rtr-Internal Medicine: Case Presentation
Rtr-Internal Medicine: Case Presentation
MEDICINE
CASE PRESENTATION
Tabajonda, Raphael Adrian M. MD
POST GRADUATE INTERN
GENERAL OBJECTIVES
-broaden the knowledge of its
audience about HYPERTHYROID
HYPOKALEMIC PERIODIC PARALYSIS;
NATURE,
RISK FACTORS
EPIDEMIOLOGY,
PATHOGENESIS,
CLINICAL MANIFESTATIONS
TREATMENT AND PROGNOSIS
DATE OF INTERVIEW: OCTOBER 12,
2018
SOURCE OF INFORMATION:
PATIENT
RELIABILITY: 95%
• A case of J.J
• MALE
• 25 years old
• born on MAY 25, 1993
• single
• Roman Catholic
• Filipino
GENERAL INFORMATION
LOWER EXTREMITIES
WEAKNESS
CHIEF COMPLAINT
History of
present illness:
- (+) WEAKNESS OF BOTH
LOWER EXTREMITIES
- (-) DYSPNEA
- (-) NAUSEA
- (-) VOMITING
- (-) CHESTPAIN
- (-) ABDOMINAL PAIN
1 week PRIOR - (-) URINARY SYMPTOMS
TO ADMISSION (x) NO MEDICATIONS WERE
TAKEN
(x) NO CONSULT WAS DONE
History of
present illness:
WEAKNESS PROGRESSES
NAUSEA
DIFFICULTY IN AMBULATION
FELL SEVERAL TIMES WITH
ABRASION TO THE KNEE
2 DAYS PRIOR • CONSULT WAS DONE AT
TO ADMISSION DISTRICT HOSPITAL
History of
present illness:
• CONSULT WAS DONE
• LABS WERE REQUESTED
• DECREASE IN POTASSIUM
NOTED < 2.5mmol/l
• Patient refused for
admission
2 DAYS PRIOR • Was given celecoxib for
TO ADMISSION pain and KCL tab 2x a day
for hypokalemia
History of
present illness:
- (+)WORSENING OF
SYMPTOMS PROMPTED
CONSULT
- ADMITTED
1 DAY PRIOR
TO ADMISSION
PAST MEDICAL HISTORY
Smoker
Alcoholic beverage drinker.
REVIEW OF SYSTEMS
GIT: poor appetite, nausea, vomiting, defecates at least once a day with a
stool brownish in color, and soft in consistency
GUT: no hematuria, dysuria, polyuria, oliguria, urinates at least 4-5 times a
day, yellow in color and amounting to 200 ml per urination.
MUSCULOSKELETAL: muscle weaakness
HEMATOLOGIC: no easy bruising
ENDOCRINE: no excessive thirst/hunger, no heat/cold intolerance
PSYCHIATRIC: no nervousness, tension, memory loss
PHYSICAL EXAMINATION
General Survey
Patient was examined conscious, coherent, oriented as to time, place and person,
cooperative, mesomorph, afebrile, not in cardio-respiratory distress, with the
following vital signs:
BP 120/70 mmHg
HR 79 bpm
RR 23 cpm
TEMP 36.1 C
PHYSICAL EXAMINATION
INTEGUMENT
Skin: dry, warm, brown complexion, no scars, good skin turgor, no jaundice, no edema, no
ecchymoses
HEAD
Hair: short, black, fine, evenly distributed on scalp
Scalp: no tenderness, no scars, no active lesions
Skull: normocephalic, atraumatic
PHYSICAL EXAMINATION
EYES:
Eyebrows: symmetrical, fine, black, no active lesions
Eyelashes: fine, black, oriented outwards
Eyelids: no edema , no sty, no lid lag
Conjunctiva: pinkish palpebral conjunctiva
Sclera: anicteric, no hemorrhage
Cornea: no opacities, no ulceration
Pupils: symmetrical, 2mm in diameter, reactive to direct & consensual light
stimulation
EOM: full
PHYSICAL EXAMINATION
HEART:
Adynamic precordium, regular rhythm synchronous with radial pulse, no
murmurs, no pericardial friction rub
ABDOMEN:
Inspection: full, symmetrical, no visible peristalsis, no visible veins
Palpation: no tenderness, spleen & kidney not palpable,
Percussion: tympanitic , no fluid wave
Auscultation: normoactive bowel sounds, no bruit, no peritoneal friction
rub
PHYSICAL EXAMINATION
EXTREMITIES:
Inspection: equal length, no deformities, no active
lesions, no edema,
Palpation: no muscular tenderness
BACK AND SPINE:
Inspection: no abnormal deviation, no muscle wasting
Palpation: no tenderness or mass
NEUROLOGIC EXAMINATION
Motor:
3/5 = LOWER EXTREMITIES
5/5 5/5
DTR:
PATELLAR & ACHILLES= HYPOACTIVE
SENSORY:
3/5 3/5
100 % INTACT
NEUROLOGIC EXAMINATION
Cerebellum
- able to perform pronation-
supination
VII. Meninges
(-) nuchal rigidity
(-) Kernig’s sign
(-) Brudzinski sign
VIII. ANS (-) excessive sweating
SALIENT FEATURES
• 25 years old
• male
• Asian
• Chief complaint: lower
extremities weakness
• Alcoholic
• Hypokalemia: < 2.8mg/dl
• Took KCL tab 2x a day
• Motor : 3/5 both lower
extremities
• Nausea
Differential diagnosis
Pivot : paraparesis
Infectious: Transverse myelitis
Diagnostics requested:
Potassium, Sodium
CBC with platelet count
12L ECG, BUN, Creatinine
TSH,FT4,FT3
Urinalysis
Chest xray PA view
Ultrasound of the abdomen
laboratories
October 12, 2018 4:58PM
HEMATOLOGY
TEST RESULTS UNIT NORMAL VALUES
COMPLETE BLOOD COUNT
WBC Count 6.5 X10^10g/L 5.0 – 10.0
Hemoglobin 155 g/L 140 – 180
Hematocrit 0.48 g/L 0.40 – 0.54
Platelet Count 348 X10^10g/L 150 – 450
DIFFERENTIAL COUNT
Neutrophils (%) 54 % 50 – 70
Lymphocytes (%) 37 % 20 – 40
Monocytes (%) H9 % 0–7
October 12, 2018 3:36 PM
ARTERIAL BLOOD GAS REPORT
ACTUAL MEASURED VALUES REFERENCE VALUES
ULTRASOUND
Attacks of thyrotoxic periodic paralysis resemble those of primary HypoKPP. Despite a higher
incidence of thyrotoxicosis in women, men, particularly those of Asian descent, are more
likely to manifest this complication.
1.)Propylthiouracil,
2.)Carbimazole and
3.)Methimazole.
large goiters
Hypertension
Laboratory findings:
Low potassium excretion rate (low urinary potassium—creatinine ratio and low TTKG)
Abnormal thyroid function tests (low TSH; elevated free and total T4 and T3; increased T3 uptake)
Electrocardiographic abnormalities:
Sinus tachycardia
Hypokalemic changes: prominent U wave, prolonged PR interval, increased P-wave amplitude, widened QRS complexes
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