case presentation on bulbar palsy

Bulbar palsy refers to impairment of function of the cranial nerves IX, X, XI and XII, which occurs due to a lower motor neuron lesion either at nuclear or fascicular level in the medulla oblongata or from lesions of the lower cranial nerves outside the brainstem.

1. CASE PRESENTATION ON BULBAR PALSY Percy arpitha . B Pharm- d V yr

2. Palsy ?? Palsy  is a medical term  which refers to various types of  paralysis ,  often accompanied by weakness and the loss of feeling and uncontrolled body movements such as shaking. 

3. Bulbar palsy ?? Bulbar palsy  refers to impairment of function of the  cranial nerves   IX, X, XI and XII , which occurs due to a   lower motor neuron  lesion either at nuclear or fascicular level in the  medulla oblongata or from lesions of the lower cranial nerves outside the brainstem.

4. Specific kinds of palsy include: Bell's palsy , partial facial paralysis Bulbar palsy , impairment of cranial nerves Cerebral palsy , a neural disorder caused by intracranial lesions Conjugate gaze palsy , a disorder affecting the ability to move the eyes Erb's palsy , also known as brachial palsy, involving paralysis of an arm Spinal muscular atrophy , also known as wasting palsy Progressive supra nuclear palsy , a degenerative disease Squatter's palsy , a common name for bilateral  peroneal nerve palsy that may be triggered by sustained  squatting Third nerve palsy , involving cranial nerve III

5. Causes Genetic:  Kennedy's disease, acute intermittent porphyria Vascular causes: medullary infarction Degenerative diseases:  motor neuron disease (amyotrophic lateral sclerosis),  syringobulbia Inflammatory/infective:   Guillain – Barré syndrome, poliomyelitis, Lyme disease Malignancy: brain-stem  glioma , malignant meningitis Toxic:  botulism, bark scorpion venom ( Centruroides sp .),some neurotoxic snake venoms Autoimmune:  myasthenia gravis

6. Pathophysiology Degeneration of the lower motor neurons with involvement of the cranial nerve nuclei in the medulla oblongata and pons that innervate the bulbar muscles results in a bulbar palsy with flaccid pareses , muscular atrophy, and fasciculation's and/or tongue fibrillations.

7. Clinical Presentation Symptoms Dysphagia (difficulty in swallowing) Difficulty in chewing Nasal regurgitation Slurring of speech Difficulty in handling secretions Choking on liquids Dysphonia (defective use of the voice, inability to produce sound due to laryngeal weakness) Dysarthria (difficulty in articulating words due to a CNS problem) Signs Nasal speech lacking in modulation & difficulty with all consonants Tongue is atrophic & shows  fasciculations . Dribbling of saliva. Weakness of the soft palate, examined by asking the patient to say aah . The jaw jerk is normal or absent. The gag reflex is absent. In addition, there may be lower motor neuron lesions of the limbs.

8. Diagnosis D etailed family history P ast medical history of the patient. Blood tests will also be conducted to rule out other causes. MRI CT scans Apart from this, an EMG study may also be performed to look at the muscle activity of the body and see if any abnormalities are present.

9. Treatment N o clear cut treatment M ainly aimed at control of symptoms In severe cases of dysphagia, an NG tube may be inserted for feeding. P hysical therapy S peech therapy

10. Demographic Data NAME: XXX AGE: 54yrs GENDER: Female I.P. NO: 4245/16 D.O.A: 11-12-16 DEPARTMENT: Neurology CONSULTANT: Dr . Naga Suresh( Neurophysician )

11. SUBJECTIVE CHIEF COMPLAINTS C/O Unable to swallow since 1 month C/O Vomiting's (3 episodes) associated dehydration + Fever + (not associated with chills and rigors) Body pains + Headache + Nasal regurgitation + Cough/ Dry cough with swallowing +

12. SUBJECTIVE PAST MEDICAL and MEDICATION HISTORY: k/c/o HTN & DM since 10 years Rx: Olmezest-20( olmesartan medoxomil ) Amaryl 1mg(Glimepiride)OD Glycomet 850 SR (Metformin) BD Calcimax (Calcium +Vitamin D3) OD Razo-D ( Rabeprazole + Domperidone ) BD And recently diagnosed bulbar palsy (10 days back)

13. SUBJECTIVE PAST SURGICAL HISTORY: Hysterectomy 8 yrs back due to uterine fibroid ALLERGIES: Nil PERSONAL HISTORY AND HABITS: No relevant information found FAMILY HISTORY: Nil significant DIET: Mixed type APPETITE: Normal SLEEP: Normal BOWEL AND BLADDER HABIT: Normal

14. OBJECTIVE Date 11 th 12 th 13 th 14 th 15 th 16 th 17 th 18 th Temp (°F) 98.6 98.6 98.6 98.6 98.6 98.6 98.6 98.6 B.P(mm of Hg) 130/ 90 130/ 90 130/ 80 130/ 90 130/ 90 100/ 70 100/ 80 120/80 P.R 76 90 90 82 84 89 80 82 R.R 22 22 24 26 32 22 24 22 General examination

15. O BJECTIVE Date 11 th 12 th 13 th 14 th 15 th 16 th 17 th 18 th CVS S 1 S 2 + S 1 S 2 + S 1 S 2 + S 1 S 2 + S 1 S 2 + S 1 S 2 + S 1 S 2 + S 1 S 2 + RS Clear Clear Clear Clear Clear Clear Clear Clear System examination

16. O BJECTIVE Test 11 th 14 th Normal value Hb 10.6 11.7 13-17 g/dl TLC 7000 9000 4000-11000cells/cum DLC N 70 75 40-80% L 25 20 20-40% E 03 03 0-6% M 02 02 2-10% Platelets 3.9 4.2 1.5-4.0 lakhs/ cumm ESR 20 20 0-20 mm/ hr Complete blood picture

17. OBJECTIVE TEST 11 th 14 th Normal range S. Sodium 143 141 135- 145 mmol /l S. Potassium 4.1 3.9 3.5- 5.5 mopl /l S. Chlorides 105 103 98-105 mmol /l Electrolytes Date 11 th 14 th Normal value BUN 23 21 10-50mg/dl S. Cr 1.0 1.0 0.6-1.6mg/dl Renal f unction tests

18. OBJECTIVE Date 11 th 12 th 13 th 14 th 19 th 20 th 21 st Normal value Blood sugar (Random) 80 110 160 - 134 210 - 80-150mg/dl Blood sugar (Fasting) - 74 116 110 110 99 60- 110 mg/dl Blood sugar tests

19. OBJECTIVE TEST TEST VALUE NORMAL VALUE Total Bilirubin 0.6mg/dl 0.0-1.0mg/dl Direct Bilirubin 0.2mg/dl 0.0-0.25mg/dl SGPT 22 IU/L 0-45 IU/L SGOT 27IU/L 0-40 IU/L Total Protein 6.4g/dl 6-8g/dl Albumin 3.1g/dl 3.5-5.5g/dl Globulin 3.3g/dl 2.3-3.6g/dl Liver function tests

20. O BJECTIVE MRI BRAIN Impression: Chronic lacunar infarct noted in left basal ganglia Mild small vessel ischemic changes noted in bilateral deep white matter Mild age related atrophic changes MRA: No significant abnormality

21. OBJECTIVE CSF Analysis Appearance : Clear Pandys test : positive Sugar : 70mgs (50-70mgs %) Proteins : 60mgs (15-45mgs) Chlorides : 102mmol/l (118-132mmol/l) Adenosine Deaminase Activity Total ADA in CSF : 09U/L (<10 U/L) Cell count RBC : 2 cells WBC : 5 cells Polycysyts : 0 Lymphocytes : 100 Fungal elements : negative Gram staining : negative AFB staining : negative

22. ASSESMENT Based on subjective and objective evidence the patient is a known case of diabetes and hypertension and diagnosed to have Bulbar palsy

23. Daily Progress Chart Day 1 (11-12-16) ON EXAMINATION S.NO DRUGS PRESCRIBED DOSE ROA FREQUENCY C/O Unable to swallow since 1 month C/O Vomiting's (3 episodes) associated dehydration + Fever + (not associated with chills and rigors) Body pains + Headache + Nasal regurgitation + Cough/ Dry cough with swallowing + 1 Inj. Razo 20mg/ml IV BD 2 Inj. Ondem 2mg/ml IV SOS 3 Inj. Human Mixtard 30/70 U/L S/C BD 4 Inj. Nootropil 200mg/15ml (60ml) IV BD 5 Tab. Olmezest 20mg PO OD 6 Tab. Clavix AS 150mg PO OD 7 Tab. Bestor 10mg PO OD 8 IVF (1 NS, 1 RL) 9 RT Feeding 10 Glucerna powder with milk 11 Tab,. Hifenac P ½ tab PO BD

24. Daily Progress Chart Day 2 (12-12-16) ON EXAMINATION S.NO DRUGS PRESCRIBED DOSE ROA FREQUENCY Gefair Afebrile Nebulization SOS + Tab . Benformet Plus 1 tab PO BD Day 3 (13-12-16) ON EXAMINATION S.NO DRUGS PRESCRIBED DOSE ROA FREQUENCY Gefair , Afebrile Swallowing small quantity of fluids with spoon Continued same treatment

25. Daily Progress Chart Day 4 (14-12-16) ON EXAMINATION S.NO DRUGS PRESCRIBED DOSE ROA FREQUENCY Dysphagia Dysphonia Difficulty in walking since 5 days with parasthesias of hand & feet H/o cold Illness fluctuation + Bilateral facial weakness Depressed Gag L.L – weakness ( prox > distal) Absent DTR No neck stiffness 1 Adv. ENMG 2 Rejunex plus 100ml/hr 3 Tab. Gabapin ME 100mg PO BD 4 Tab. Maxgalin 50mg PO OD 6 Inj. Pantop 40mg/2ml IV OD

26. Daily Progress Chart Day 5 (15-12-16) ON EXAMINATION S.NO DRUGS PRESCRIBED DOSE ROA FREQUENCY Gefair Dysphagia + Concious / coherent Language (N) Continued same treatment Day 6 (16-12-16) ON EXAMINATION S.NO DRUGS PRESCRIBED DOSE ROA FREQUENCY Concious / coherent Quadriperesis BP: 100/70 Continued same treatment

27. Daily Progress Chart Day 7 (17-12-16) ON EXAMINATION S.NO DRUGS PRESCRIBED DOSE ROA FREQUENCY Gefair PR: 82bpm BP: 100/80 mm Hg Quadriperesis Power improved marginally 1 Inj . IvIg 2g/kg Total of 100gm in divided doses for 5 days Day 1: Pre medication Inj. Avil 1amp IV STAT Inj. Decadran 4mg IV STAT Day 2: 20gm to be given (Total of 4 vials)

28. Daily Progress Chart Day 7 (17-12-16) ON EXAMINATION S.NO DRUGS PRESCRIBED DOSE ROA FREQUENCY Continued… 2 Inj. Pantop 40mg/2ml IV BD 3 Tab. Olmezest 20mg PO OD 4 Tab. Ecosprin AV 1 tab PO OD 5 Tab. Gabapin ME 100mg PO BD 6 Tab. Maxgalin M 50mg PO OD 7 Cap. Benformet Plus 1 Cap PO OD 8 Tab. Dolo 650mg PO SOS 9 Tab. Cremalax 1tab PO OD 10 Inj. Human Actrapid As per GRBS 11 IVF (1 NS, 1 RL) with Rejunex plus 100ml/ hr 12 Physiotherapy

29. Daily Progress Chart Day 7 (17-12-16) ON EXAMINATION S.NO DRUGS PRESCRIBED DOSE ROA FREQUENCY Inj. IvIg started ( 1 st dose) Started at Stopped at 1 st vail (5gm) over 4hrs 10: 50 AM 02:50 PM 2 nd vail (5gm) over 4hrs 03:00 PM 07 : 00 PM 3 rd vail (5gm) over 2 hrs 07 : 00 PM 09: 00 PM 4 th vail (5gm) over 2hrs 09: 00 PM 11:00 PM

30. Daily Progress Chart Day 8 (18-12-16) ON EXAMINATION S.NO DRUGS PRESCRIBED DOSE ROA FREQUENCY Gefair Conscious/ Oriented PR: 90bpm BP: 120/80 mm Hg CST+ 2 nd dose Stop Maxgalin Add : Tab. Pregabalin forte 75mg OD Started at Stopped at 1 st vail (5gm) over 4hrs 11: 10 AM 03:00 PM 2 nd vail (5gm) over 4hrs 03:00 PM 07 : 00 PM 3 rd vail (5gm) over 2 hrs 07 : 00 PM 09: 00 PM 4 th vail (5gm) over 2hrs 09: 00 PM 11:00 PM

31. Daily Progress Chart Day 9 (19-12-16) ON EXAMINATION S.NO DRUGS PRESCRIBED DOSE ROA FREQUENCY Gefair Afebrile Dysphagia + PR: 90bpm BP: 120/80 mm Hg CST+ 3 rd dose Started at Stopped at 1 st vail (5gm) over 4hrs 11: 30 AM 03:30 PM 2 nd vail (5gm) over 4hrs 03:30 PM 07 : 30 PM 3 rd vail (5gm) over 2 hrs 07 : 30 PM 09: 30 PM 4 th vail (5gm) over 2hrs 10: 00 PM 12:00 PM

32. Daily Progress Chart Day 10 (20-12-16) ON EXAMINATION S.NO DRUGS PRESCRIBED DOSE ROA FREQUENCY Gefair Hematuria + PR: 90bpm BP: 120/80 mm Hg 4 th dose Stop Ecosprin AV Started at Stopped at 1 st vail (5gm) over 4hrs 10: 40 AM 02:40 PM 2 nd vail (5gm) over 4hrs 02:40 PM 04 : 40 PM 3 rd vail (5gm) over 2 hrs 04 : 40 PM 06 40 PM 4 th vail (5gm) over 2hrs 06: 40 PM 08:40 PM

33. Daily Progress Chart Day 11 (21-12-16) ON EXAMINATION S.NO DRUGS PRESCRIBED DOSE ROA FREQUENCY Gefair Afebrile Hematuria + PR: 90bpm BP: 130/80 mm Hg CST+ 5 th dose Started at Stopped at 1 st vail (5gm) over 4hrs 11: 30 AM 03:30 PM 2 nd vail (5gm) over 4hrs 03:30 PM 07 : 30 PM 3 rd vail (5gm) over 2 hrs 07 : 30 PM 09: 30 PM 4 th vail (5gm) over 2hrs 10: 00 PM 12:00 PM

34. PLANNING S. no Brand name Generic name Dose ROA Freq Duration of Therapy 1. Inj. Razo Rabeprazole 20mg/ml IV BD 11-12-16 to 13-12-16 2 Inj. Ondem Ondansetron 2mg/ml IV SOS 11-12-16 to 17-12-16 3 Inj. Human Mixtard Insulin Isophane 30/70 U/L S/C BD 11-12-16 to 17-12-16 4 Inj. Nootropil Piracetam 12g/60ml IV BD 11-12-16 to 17-12-16 5 Tab. Olmezest Olmesartan Medoxomil 20mg PO OD 11-12-16 to 17-12-16 6 Tab. Clavix AS Aspirin+ Clopidogrel 75mg+ 75mg PO OD 11-12-16 to 17-12-16 7 Tab. Bestor Rosuvastatin 10mg PO OD 11-12-16 to 17-12-16

35. PLANNING S. no Brand name Generic name Dose ROA Freq Duration of Therapy 8 Tab. Hifenac P Aceclofenac + Paracetamol 100mg+ 625mg PO BD 11-12-16 to 17-12-16 9 Tab. Benformet Plus Benfotiamine + Alpha lipoic acid+ Mecobalamin + Pyridoxine hydrochloride 100mg+ 100mg+ 0.5mg+ 50mg PO BD OD 12-12-16 to 13-12 -16 14-12-16 to till date 10 Tab. Gabapin ME Gabapentin+ Mecobalamin 100mg+ 500mg PO BD 14-12-16 to till date 11 Tab. Maxgalin Pregabalin 50mg PO OD 14-12-16 to 17-12-16 12 Inj. Pantop Pantoprazole 40mg/2ml IV OD 14-12-16 to till date

36. PLANNING S. no Brand name Generic name Dose ROA Freq Duration of Therapy 13 Inj. Solumedrol Methyl prednisolone 1gm IV OD 16-12-16 14 Inj. Globuwok Human Immunoglobulin 5gm/ 100ml IV 17-12-16 to till date 15 Inj. Ecosprin AV Aspirin + Atorvastatin 75mg+ 10mg PO OD 17-12-16 to till date 16 Tab. Dolo Paracetamol 650mg PO SOS 17-12-16 to till date 17 Tab. Cremalax Sodium picosulphate 10mg PO OD 17-12-16 to till date 18 Tab. Pregalin forte pregabalin 75mg PO OD 18-12-16 to till date

37. Pharmacist Intervention ( Diet & Nutrition) A healthful eating plan is a mainstay of preventing nerve damage  I nclude foods high in B12 in your diet, such as poultry, fish, lean meat, eggs, and fortified cereals Go vegan. In a recent study called DINE (Dietary Intervention for Chronic Diabetic Neuropathy Pain), people with Type 2 diabetes and neuropathy were assigned to either a low-fat, vegan (no animal products) diet with B12 supplements or B12 supplements alone (control group). The people following the vegan diet reported less pain and other neuropathy symptoms and improvements in A1C, cholesterol, and quality of life compared to the control group.

38. Pharmacist Intervention ( Diet & Nutrition) Alcohol may worsen neuropathy symptoms. Drinking too much alcohol may also make it harder to control your blood sugar levels . Certain dietary supplements may be helpful for easing symptoms of neuropathy.  A lpha- lipoic acid Fish oil supplements Curcumin (found in the spice turmeric ) and evening primrose oil

39. Pharmacist Intervention Drug –Drug Interactions Major ACECLOFENAC  -- ASPIRIN: may result in increased risk of bleeding . ACECLOFENAC -- METHYLPREDNISOLONE SODIUM SUCCINATE : may result in increased risk of gastrointestinal ulcer or bleeding . ASPIRIN  -- PIRACETAM: may result in increased risk of bleeding .

40. Pharmacist Intervention Drug –Drug Interactions Minor ACECLOFENAC  -- OLMESARTAN MEDOXOMIL: may result in renal dysfunction or decreased antihypertensive efficacy. ASPIRIN  -- METHYLPREDNISOLONE SODIUM SUCCINATE: may result in an increased risk of gastrointestinal ulceration and sub therapeutic aspirin serum concentrations.

41. Thank You