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Dr ANVESH NARIMETI
POSTGRADUATE
MD GENERAL MEDICINE
GANDHI MEDICAL COLLEGE/HOSPITAL
NAME Anwar
AGE 33yrs
SEX male
OCCUPATION Daily labourer
RESIDENCE Ameerpet
ADMISSION 8/6/2014 11.00am
Weakness of both upper and lower limbs from last
7hours
Patient was apparently normal yesterday went to
work and came back in the evening and had food
and slept without any complaints.In early hours of
next day morning patients got up to use wash room
and observed that he is unable to get up and move
his upper limbs and lowerlimbs
Weakness is sudden in onset and generalised
involving both proximal and distal muscles.
Weakness is associated with pain in the limbs
No h/o of paresthesias,bladder or bowel involvement
No h/o suggestive of cranial nerve involvement
No h/o of any trauma
No h/o of any drug intake
No h/o of fever
No h/o of any vaccination
No h/o of dog bite
History of similar 5 episodes usually in summer
seasons after excessive exhaustion during work and
use to recover after taking medications which he is
use to get from gandhi hospital. Patient used to
recover in one day and get discharged
No history of any fatiguability, diplopia during his
routine work
In between the episodes patient used to absolutely
well and used to perform all activities without any
difficulty
Mixed diet
No addictions
Bowel and bladder habits are normal
No other family member suffering from similar
complaints
A 33 yr old young male came with sudden onset
quadriparesis occurred over hours and recovering in
2days with history of similar episodes in the past
ELECTROLYTE DISTURBENCES
MUSCLE DISORDERS
NEURO MUSCULAR JUNCTION DISORDERS
CENTRAL NERVOUS SYSTEM DISORDERS
Moderately built and moderately nourished
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No pedal edema
No external signs of dehydration
No thyroid swelling
Blood pressure – 130/80 mm of hg rt upper limb in
supine position
Pulse rate- 86 per min regular in rhythm and normal
volume.
Respiratory rate- 16 / min and abdomino-thorasic
type of breathing
Higher mental functionsPatient conscious ,coherent , oriented in
time , place and person
Memory and intellect – normal
Speech – fluency ,comprehension , naming
and repeation are normal
No hallucinations and dellusions
CRANIAL NERVES EXAMINATION -
NORMAL
Bulk – normal
Tone – normal tone in all limbs
Power
Upperlimbs
Shoulder
Flexors
Extensors
Adductors
abductors
1/5 1/5
1/5 1/5
1/5 1/5
1/5 1/5
ElbowFlexors
Extensors
WristFlexor
Extensor
Hand grip – not able to hold finger
lowerlimbHip
Flexor
Extensor
Adductors
Abductors
1/5 1/5
1/5 1/5
1/5 1/5
1/5 1/5
1/5 1/5
1/5 1/5
1/5 1/5
1/5 1/5
KneeFlexionr
Extension
AnklePlantar flexion
Dorsi flexion
Reflexes
Superficial
Plantars
Abdominals
corneal
1/5 1/5
1/5 1/5
1/5 1/5
1/5 1/5
flexors flexors
present present
Present present
Deep tendon reflexes
Biceps
Triceps
Supinator
Knee
Ankle
- -
- -
- -
- -
- -
• Pin prick, Fine touch , vibration and joint
sensation normal
Cortical sensations normal
Cerebellum
No nystagmus
No ataxia
Tests for coordination were not able to perform
Liver and spleen not palpable
No shifting dullness
Per abdomen is soft
Inspection – normal, trachea midline , apical impulse
in left 5th ICS medial to mid clavicular line
Palpation – normal
Percussion – resonant note all areas
Ascultation – vesicular BS in all areas
no added sounds
Inspection – normal
Palpation – no palpable sounds , thrills
Percussion – left heart border corresponds to the
apex , right heart border corresponds to the right
sternal border
Ascultation – S1 + , S2 + , S3 - , S4 - , no murmurs
ELECTROLYTE DISTURBENCES
PERIODIC PARALYSIS
COMPLETE BLOOD PICTURE – NORMAL
RBS-168mg/dl
Blood urea- 30mg/dl
Serum creatinine- 1.0mg/dl
Serum electrolytes- sodium 138
potassium 2.8
chloride 94
magnesium 1.2mg/dl(1.5-2.3)
calcium – 10.6
chest xray – normal study
ECG- showing features of hypokalemia
Thyroid profile – normal
Ultra sonography- normal study
24hrs urinary electrolytes-
1. Sodium 322 meq (100-260)
2. Potassium 144 meq^(25-100)
3. Chloride 516.6 meq^ (110-250)
Serum osmolarity = 2x (sodium)+blood
urea/5.4+RBS/18 = 290 mosm
urine osmolarity = 2x(sodium+potassium)+urine
urea/5.4 =1839 mosm
What is TTKG ?
What does it assess?
What are the prerequisites?
TTKG is the ratio of potassium concentration in the
lumen of CCD to that in peritubular capillaries.
Asseses the net driving force of potassium excretion
Urine osmolarity should exceed that of plasma
osmolarity inorder to calculate an interpretable TTKG
TTKG = Uk x Posm
Sk x Uosm
During hypokalemia -TTKG should fall <3 -
indicating appropriately reduced urinary excretion
of K
TTKG > 4 – indicates renal K loss is due to
increased distal K secretion
TTKG- 8.1
BLOOD PRESSURE IS NORMAL
ABG 8/6/2014 10/6/2014
PCO2 42.15mm hg 41.82mm hg
PH 7.47 7.49
K+ 2.01mmol/l 2.97mmol/l
HCO3 27.18mmol/l 26.76mmol/l
Metabolic alkalosis
URINE CHLORIDE – 516MEQ (> 20)
NEXT STEP MEASURE Urinary calcium/ creatinine
ratio
Urinary calcium /creatinine ratio =0.026 ( <0.15)
GITELMAN’S SYNDROME
AUTOSOMAL RECESSIVE DISORDER
PRESENTS IN LATE CHILDHOOD OR ADULTHOOD
HYPOKALEMIA
METABOLIC ALKALOSIS
HYPOMAGNESEMIA
HYPOCALCIURIA
NORMAL BLOOD PRESSURE
CLINIACL MANIFESTATIONS LESS PRONOUNCED IN HETEROZYGOTES
Cramps of arms and legs which may be severe due
to hypokalemia and hypomagnesimia
Fatigue
Polyuria and nocturia
Chondrocalcinosis related to chronic severe
hypomagnesemia
Mutations in the gene coding for the thiazide
sensitive Na Cl cotransporter in distal tubule NCCT,
SLC12A3.
Life long treatment as tubular defect cannot be
corrected
Treatment aimed at minimising the effects of
secondary increase in renin and aldosterone
production
Correcting electrolyte abnormalities
Potassium sparing diuretics are better than
potassium suplementation.
Spiranolactone> amiloride
Potassium and magnesium supplementation