A 45 year old woman with no appetite, nausea, weakness in both legs

This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with collective current best evidence-based inputs

PRESENTING COMPLAINT -A 45 year old woman presented to casualty with complaints of excessive weakness and fatigue in both her legs and also her upper limbs. Due to this weakness, she fell down when attempted to walk and hence brought to the hospital. 

ASSOCIATED COMPLAINT
She also complains of loss of appetite and feeling of nausea when she tried eating. 
She also complains of moderate weakness in her entire body. 


HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 5 days back.4 days back, on Monday (29/05/23) 
She had weakness in her legs which started in the morning and gradually increased through the day. She also had no appetite. When she was forced to eat, she felt nauseous. 
She was able to do her normal household work despite the pain and weakness but... 
On Tuesday, ( 30/05/23) morning.. 
She tried walking despite her weakness but fell down and hit her head on the floor.

HISTORY OF PAST ILLNESS
No diabetes
No hypertension
No epilepsy
No thyroid disorders
No asthma
No TB
No CAD
History of Renal calculi

SURGERY HISTORY
Patient underwent hysterectomy 2 months back. 
No history of blood transfusions

PERSONAL HISTORy
Married
Mixed diet
Adequate slsleep till 5 days back. Couldn't sleep from monday due to pain
Loss of appetite since 4 days
Normal bladder
Normal bowel
No burning micturition
No addictions
No allergies

DRUG HISTORY
Took tablets for 4 weeks after her hysterectomy surgery. And then stopped( patient couldn't name the medicine or show us a sample) 

FAMILY HISTORY
no similar family history of weakness, fatigue and pain. 
No dm 
No htn
No thyroid
No asthma epilepsy tb cad

PHYSICAL EXAMINATION
Patient was 
Conscious, coherent and cooperative
Well oriented with time, space and person
Moderately built and nourished
No palor
No icterus
No central cyanosis
No peripheral cyanosis

No clubbing of fingers
No lymphadenopathy
No edema

VITALS
Bp - 108/95
Repiratory rate - 26 /min
Temperature - afebrile

REPORTS

TREATMENT
injection KCL 40 Meq in 500 ml normal saline
Injection Optineuron 1 ampule in 500 ml normal saline I. V O D
Monitor vitals

Patient discharged


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