Case history-9
A 40 yr old female with HYPOKALEMIA
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2/12/21
DATE OF ADMISSION:25/11/21
A 40 yr old female came to the opd with the chief complaint of sudden weakness bilateral upper limb and lower limb.
HISTORY OF PRESENT ILLNESS:
Daily routine -The lady wakes up mrng by 5:30-6:00am and have tea then she cooks the food and have her breakfast (rice )at 9am and goes to farming works by 10am and have her lunch (rice,dal)by 1or 2 pm and come back home by 6pm in evng and relaxes and makes food for dinner and have dinner at 8pm and goes to bed by 10pm .
The patient was apparently asymptomatic 3yrs back and the developed weakness inthe upper and lower limb every summer .They visited the nearby hospital and got pottasium ions injected . No h/o vomitings ,pain abdomen chest pain ,palpitations,sob ,cough ,cold ,bleeding manifestations ,bleeding gums ,purpura .
H/o constipation.
HISTORY OF PAST ILLNESS :
Not a k/c/o HTN/DM/TB /ASTHMA /CAV/CDA
PERSONAL HISTORY:
Married ,normal appetite,nonvegetarian,regular bowel movement,micturation -normal ,no known allergies ,no addictions
FAMILY HISTORY:
No history of diabetes, hypertension, heart disease, stroke, asthma, tuberculosis,cancers .
General examination:
The patient is conscious, coherent, cooperative .
Palar-present
No cyanosis
No lymphadenopathy
malnutrition -present
No dehydration
No clubbing
No icterus
No Edema
VITALS :
Temp :afebrile
Pulse rate:83/min
Respiratory rate:18cpm
Bp:100/70mm/hg
Spo2-99%of o2
SYSTEMIC EXAMINATION:
CVS :
No thrills
No cardiac murmurs
Cardiac sounds-s1,s2 heard
RESPIRATORY SYSTEM :
Dysponea-present
No wheeze
Position of trachea-central
Breath sounds-vesicular
ABDOMEN:
Shape of abdomen-scaphoid
No tenderness
No palpable mass
Hernial orifices-normal
No free fluid
No bruits
Liver ,spleen-not palpable
Bowel sounds -yes
CNS:
Conscious
Normal speech
No neck stiffness
No kernings signs
Cranial nerves ,motor and sensory system,glasgow scale -normal .
PROVISIONAL DIAGNOSIS:
HYPOKALEMIA
Hypomagnesia
INVESTIGATIONS:
25/11/21:
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