Incase_Akmal_29 nov_ acute diffuse weakness.pptx

diagnostic approach in acute weakness

1. Interesting Case Reza, Ali, Dhatu, Amanda, Vanda, Arka , Akmal Akmalia Fatimah (Akmal) Diagnostic Approach of Acute Diffuse Weakness in Children Wednesday , November 28 th 2023

2. AAF, male, 5 years and 8 months old   Lower and upper Extremities Weakness Akmalia Fatimah (Akmal)

3. 10 days before admission Patient experienced cough and runny nose without fever, nausea or vomiting or painful swallowing It was productive cough and happened frequently 8 days before admission Patient started experiencing painful in his both legs and arms The pain cannot be localized Especially happened when he woke up in the morning He cannot wore his dress alone The cough is persisted Akmalia Fatimah (Akmal)

4. a week before admission He was not able to walk He started to feel weak and pain in his both legs Then it spread to his arms too not able to sit by his own sometimes chocked when dringking He was having hoarseness with his voice He went to see a doctor and check for some examination Hb 11.4, AL 9.76, AT 741 , LED 22, CRP<6, RF <6 4 days before admission He only able to lying on the couch Arms and legs getting more and more difficult to move Painful in arms and legs still persisted He start cannot hold her urine His frequency of defecation decreased. He then was given lactulose Akmalia Fatimah (Akmal)

5. a week before admission He experienced a much painful feeling in his arms and legs He then rushed to the ER 4 days before admission He only able to lying on the couch Arms and legs getting more and more difficult to move Painful in arms and legs still persisted He start cannot hold her urine His frequency of defecation decreased. He need lactulose to defecate Akmalia Fatimah (Akmal)

6. PATIENT HISTORY Past illness history no similar symptom of the same complaint His grandfather and mother had Diabetes mellitus had history of hypertension and stroke There were no history trauma There was no history of similar disease He experienced similar complaint in 2021 but only happened in his legs also he still able to walk He was told he had septic arthritis He was given antibiotic and the symptom resolved Lung tuberculosis in 2020  treat for 6 months There w as past illnes s history that might be related to the current condition Family history Akmalia Fatimah (Akmal)

7. PATIENT HISTORY Akmalia Fatimah (Akmal) He lives with his parents, his younger sister and her grandmother Father was private employee. Mother was a housewife Got Government health insurance. 0 – 6 mo: exclusively breastfed. 6 – 12 mo: complementary feeding + breast milk. 12 mo – now: family meal a dequate feeding history Feeding History Moderate economic status Socioeconomic status Developmental milestone Currently in kindergarten Emotionally stable Socialize well There was no developmental delay

8. P1A1, 27-years-old mother no history of diseases, fever or swelling of lymph nodes Routine antenatal care visit to midwife and obstetrician. No abnormality in USG examination during pregnancy Pregnancy History 38 weeks by pervaginam delivery Born immediately cried, Birth weight: 2900g, birth length: 48 cm Birth History meconeum and micturition in 24 hours No history of icteric or bluish skin colour No difficulty of breath after discharged from hospital Postnatal History Good prenatal, natal, and post natal history Akmalia Fatimah (Akmal)

9. Immunization Basic Immunization Hepatitis B0, OPV0 BCG DPT 1 – HiB - H ep B 1 – Polio 1 DPT 2 – Hi B - H ep B 2 – Polio 2 DPT 3 – HiB - H ep B 3 – Polio 3 Measles Immunization completed based on government program                 Covid immunization - Akmalia Fatimah (Akmal) B ooster Immunization DPT 4 – HiB - H ep B 4 – HiB 4 Measles

10. NUTRITIONAL STATUS Akmalia Fatimah (Akmal) M ale Weight Height 5 years 8 months old 13.5 kg 105 cm Weight for age 67.5% Height for age 92% Waterlow 79% Height age 4 years and 6 months Weight age 2 years and 8 months Underweight, Normoheight , moderate acute malnutrition

11. Family Tree 5 years, 8 months old 1 yo 38 yo 60 yo 59 yo Akmalia Fatimah (Akmal) 31 yo 33 yo 68 yo 65 yo 18 months Diabetes Melitus GBS susp No history of family disease related to his current illness 34 yo

12. PHYSICAL EXAMINATION Appearance : alert PCS : E4V5M6 compos mentis BP : 90/67 HR : 97x/minute RR : 20 x/minute Temp : 36.7 o C SpO 2 : 97 % room air Head : i sochoric pupil 3 mm/3 mm, pupil didn ’t constrict fully with direct light examination , no anemic conjunctival , no icteric sclera, no swollen eyes, Neck : no lymph node enlargement Thorax : symmetrical chest expansion, no retraction Pulmo : V esicular breathing sound, no ronkhi , no wheezing Cor : Single sound S1, non fixed split S2, no murmur, no gallop Abdomen : N ot distended , normal bowel sound, hepar and lien not palpable, no kidney ballotement , no costovertbrae angle tenderness Extremities : warm extremities, CRT < 2 seconds, no edema , allodynia, hyporeflex , flaccid November 25th 2023 Akmalia Fatimah (Akmal)

13. NEUROLOGICAL EXAMINATION Arm Leg Right Left Right Left Movement limited limited limited limited Strength 3 3 3 3 Trophy Eutrophy Eutrophy Eutrophy Eutrophy Tonus Eutonus Eutonus Eutonus Eutonus Physiological reflex + 1 + 1 + 1 + 1 Babinski reflex No No Sensibility difficult to asses difficult to asses difficult to asses difficult to asses Clonus Negative Negative Negative Negative Meningeal sign Nuchal rigidity (-) Gower sign negative tetraparesis flaccid e.c LMN lession

14. § Cranial nerves: § N. I : difficult to evaluate. § N. II : symmetric pupil (3mm/3mm), but hardly constrict when the light is shined, visual acuity reached to 3/60. § N III, IV, VI: Normal movement of the eye § N. VII: no abnormality. § N. VIII: difficult to evaluate. § N. IX, X: no abnormality § N. XI: difficult to evaluate. § N. XII: able to stick out the tongue.

15. Laboratory Result Akmalia Fatimah (Akmal) Parameter 25/11 Normal range H b 10.8 10.2 – 15.2 Hematocrit 37.3 3 4 .0 – 48 .0 MCV 62.1 78.0-94.0 MCH 18.0 23.0-31.0 MCHC 29.0 32.0- 36.0 Platelet 748 150 - 450 Leukocyte 16.5 6.0-18.0 % neutrophil 59 22.0-46.0 % lymphocite 31.3 48.0- 78.0 CBC Thrombocytosis

16. Parameter 27/11 Normal range Sodium 140 136-145 Potassium 4.5 3.5-5.1 Chlorida 105 98-107 Calsium 2.44 2.25-2.75 Magnesium 2.4 1.7- 2.3 Phosphor 4.4 3.7-6.5 Parameter 27/11 Normal range BUN 17 5-18 Cr 0.33 0.29-0.47 GFR 133 >90 Laboratory Result Parameter 27/11 Normal range CK 146 39-308 KED 8 0-15 Electrolyte Parameter 27/11 Normal range SGOT 35 10-50 SGPT 14 10-50 Normal electrolyte, liver function, renal function

17. Data list Diagnosis Plan 1 Male, 5 yers 8 months old History taking : Weakness in both legs and arms Physical Examination: Hyporeflex , flaccid, allodinia Laboratory Examination : Normal result GBS susp dd Transverse Myelitis IV Paracetamol 10-15/kg/8 hours Pro Lumbal punction AFP surveillance 2. Male, 5 yers 8 months old History taking : Painful in legs and arms Laboratory Examination : Thrombocytosis JIA susp Check for ANA IF DATA LIST AND DIAGNOSIS Akmalia Fatimah (Akmal)

18. Data list Diagnosis Plan 3 Male, 5 yers 8 months old Physical Examination: Weight for age 67.5% Height for age 92% Waterlow 79% Underweight, Normoheight , moderate acute malnutrition - Diet based on RDA E: 90 kkal /kg/day P: 1.2 gr/kg/day ~ F: HS Nasi type B 3x1 DATA LIST AND DIAGNOSIS Akmalia Fatimah (Akmal)

19. Interesting Point Akmalia Fatimah (Akmal) Diagnostic Approach of Acute Diffuse Weakness in Children .

20. DEFINITION Weakness is a sign of negative motor sign Weakness is inability to generate normal voluntary forces in a muscle Acute weakness= acute flaccid paralysis In the ER setting paralysis is usually not accompanied by spacticity Akmalia Fatimah (Akmal)

21. Etiology Akmalia Fatimah (Akmal)

22. GBS VS Transverse Myelitis Akmalia Fatimah (Akmal)

23. Kirana Mustikasari (Kirana)