General Data

D.A.V., 24 y/o, Male, Single, Catholic, Unemployed, born on April 19, 1991 in Quezon City, presently residing at Block 29 Lot 18 Verde Heights Subdivision San Jose Del Monte Bulacan, admitted for the 3rd time at FEU-NRMF Medical Center on August 12, 2015

Chief Complaint

BODY WEAKNESS

Interval History

• This is a known case of Caustic Ingestion with Severe Erosive Esophagitis

• Status Post Esophagogastroduodenoscopy• Status Post Laparoscopic tube Jejunostomy

Insertion

• 1 month PTA, he experienced body weakness with decrease in grip strength and weight loss as evidenced by loosening of clothes.

• There was no change in his daily activities.• No associated signs and symptoms such as

fever, vomiting, diarrhea, facial asymmetry, slurred speech and paralysis.

• No medications were taken. No consult was done.

• 1 week PTA, he collapsed while walking due to the progression of body weakness.

• No loss of consciousness reported.• Activities of daily living with assistance• He also had moderate grade fever of 39 degree

Celsius, chills and episodes of difficulty of breathing.

• Sponge bath was done to relieve the fever.• No medications were taken. No consult was done.

• Few hours PTA, he could no longer walk nor stand up.

• He was brought to FEU-NRMF Medical Center ER for consult.

• Laboratory Examination showed low Potassium level, hence admitted.

Past Medical History

• (+) chicken pox, measles and mumps• Immunizations were unrecalled• March 2015: admitted at FEU-NRMF Medical

Center due to ingestion of TUFF toilet cleanser. (+) Auditory Hallucinations.

• July 2015: admitted at FEU-NRMF Medical Center due to vomiting for 13 days.

• (+) allergy to seafoods

Family History

• Father: deceased at 72 due to Pneumonia• Mother: 58 years old with Hypertension• He was the 2nd among 3 siblings.• Eldest: Male, 30 years old, apparently well• Youngest: Male, 20 years old, apparently well• No family history of DM and cancer

Personal and Social History• 1 year vocational course in Mechanics. • Food preferences include chicken, vegetables and fish.• Use of illicit drugs such as Marijuana 4 days a week (paraphernalia:

1 stick/rolling paper or use of bong) and Methamphetamine 3 sessions per day for a week

• Alcoholic beverage drinker (3 bottles of beer 3x a week) since 2011. • Started smoking 10 sticks per day last year but quit last March 2014. • Difficulty sleeping at night with 5 hours of sleep/day.• He lives with his parents and siblings in a bungalow type of house

that has 1 window and is well-ventilated.• source of water is from Nawasa.• Waste is collected twice a week.

Review of Systems

• (+) weight loss of 26 kilograms since March 2015

Physical Exam

• Jejunostomy tube at the right lower quadrant

DIFFERENTIAL DIAGNOSIS

Ischemic Stroke

• characterized by the sudden loss of blood circulation to an area of the brain, typically in a vascular territory, resulting in a corresponding loss of neurologic function.

RULE IN RULE OUT

Body weakness (gradual onset)Cigarette smokerIllicit drug useAlcohol beverage drinkerCollapsed 2x, 1 week PTA

Sudden onset

(-) Neurological deficits (monocular or binocular visual loss, visual field deficits, diplopia, dysarthria, facial asymmetry, ataxia, paralysis)

(-)Cardiac arrhythmias

Dehydration

• occurs when water intake is less than water loss

• Common causes of dehydration include vigorous exercise, especially in hot weather; intense diarrhea; vomiting; fever or excessive sweating

RULE IN RULE OUT

Vomiting 2x, 1 week PTAOne episode of moderate grade fever (39⁰C)Body weakness

(-)Signs of dehydration like dry mouth,lightheadedness,muscle cramps, andpalpitations

(-) reduced urine output and darkening of the urine

Anemia

• Anemia is caused by either a decrease in production of red blood cells or hemoglobin, or an increase in loss (usually due to bleeding) or destruction of red blood cells

• Men, hemoglobin level of less than 13.5 gram/100 ml

• Women, hemoglobin of less than 12.0 gram/100 ml.

RULE IN RULE OUT

Body weakness

severe erosive esophagitis (5 mos ago)

Jejunostomy tube at RLQ (duodenum, (primary site for iron absorption) is bypassed)

(-) Tachycardia, dyspnea, angina

Normal capillary refill time

Hypokalemia

• Defined as plasma K concentration of <3.5 mM

• Can be caused by redistribution of K between tissues and ECF or by renal and non-renal loss of K

Clinical features

• Can have adverse effects on cardiac rhythym, blood pressure and cardiovascular morbidity

• Has prominent effects on cardiac, skeletal and intestinal muscle cells

• ECG changes – broad flat T waves, ST depression, QT prolongation

• Effects on kidney – NA,Cl, HCO3 retention, polyuria, phosphaturia, ammoniagenesis

PATHOPHYSIOLOGY

MANAGEMENT

• Lab– Serum Mg

• Adequate nutrition

• K+ repletion– Mild to moderate (3-3.5 meq/l): oral KCl at 60-80

meq/day– Severe (<3 meq/l): rapidly• 40-60 meq raises 1-1.5 meq/l• 135-160meq raises 2.5-3.5 meq/l• IV KCl 20-40 meq K+ added to each liter of dextrose or

saline at a rate of 10-20 meq/h

• Decrease Na intake

THANK YOU!