Case Report

P ER IO D IC PA R A LY S IS
H Y P O K A LEM IC

By:
Tuko Gustari Lisa
1508434426

Supervisor:
dr. Riki Sukiandra, Sp.S

DEPARTMENT OF NEUROLOGY
MEDICAL SCHOOL RIAU UNIVERSITY
RSUD ARIFIN ACHMAD
PEKANBARU
2017
PATIEN TS ID EN TITY
Name Mrs. VY
Age 36 years
Gender Female
Perum muara fajar street,
Address
Rumbai, Pekanbaru
Religion Moslem
Marital Status Married
Occupation Teacher

Date of Admission January, 14th 2017

Medical Record 4973xx

Anam nesis

Chief Complaint
The weakness of arms and legs since
3 days before admitted to hospital
Anam nesis

Present Illness History

Since three days before admitted to the hospital,

suddenly the patient felt weakness in her arms and
legs. The weakness felt all day and was not diminished
by rest. The weakness become severe day by day, it
made the patient unable to stand anymore. Patients
also felt numbness in the hands and feet. Fever (+),
nausea (+), vomit (-), seizures (-), headache (-), oblique
mouth (-), shortness of breath (-), defecate and urinate
were normal. After that, the patient was brought to the
emergency room at Arifin Achmad General Hospital.
Anam nesis

Present Illness History

Two months before, the patient first complained about

weakness and fatigue. Patients also had nausea, so the
patient was difficult to eat. She lost her weight for
about 11 kg in 2 months because patients did not want
to eat. Patients felt weakness in arms and legs, but she
still could do her daily activities.
Anam nesis
Past Illness History
Hypertension (-)
Diabetes mellitus (-)
Cardiovascular disease (-)

Family Illness History

No history of Hypertension
No history of Diabetes mellitus
No history of Cardiovascular disease

Socioeconomic History
Smoker (-)
Alkohol (-)
TH E SU M M A RY O F
A N A M N ESIS
Since 3 days before admitted to the hospital,
the patient suddenly complained about
weakness in her arms and legs. Weakness felt
all day and was not diminished by rest. The
weakness become severe and made the
patient unable to stand. Patients also felt
numbness in the hands and feet. Since two
months ago, the patient already complained
about her weakness and fatigue.lost weight
(+).
P H YSIC A L EX A M IN ATIO N
General status
Blood Pressure : 110/80 mmHg
Heart Rate : 82 bpm
Respiratory Rate: 20 times per
minute
Temperature : 36.8C

P H YSIC A L EX A M IN ATIO N

Neurological status
Consciousness : Composmentis
GCS : 15
Noble Function : Normal
Neck Stiffness : Negative
Cranial nerve 1-12 : Normal
P H YSIC A L EX A M IN ATIO N
MOTOR SYSTEM

Right Left Interpretation

Upper Extremity
Strength
3 3
Distal
3 3
Proximal
Flaccid Flaccid
Tone
Eutrophy Eutrophy
Trophy
(-) (-)
Involuntary movements
(-) (-)
Clonus Tetraparese
Lower Extremity ( LMN Type)
Strength
3 3
Distal
3 3
Proximal
Flaccid Flaccid
Tone
Eutrophy Eutrophy
Trophy
(-) (-)
Involuntary movements
(-) (-)
Clonus
Body
Trophy Eutrophy Eutrophy
Normal
Involuntary movements (-) (-)
Abdominal Reflex (-) (-)
P H YSIC A L EX A M IN ATIO N
SENSORY SYSTEM
Interpretati
Right Left
on
Light Touch (+) (+)
Pain (+) (+)
Temperature (+) (+)
Proprioceptive
Position (+) (+) Normal
Two point discrimination (+) (+)
Stereognosis (+) (+)
Graphestesia (+) (+)
Vibration No Tested No Tested
P H YSIC A L EX A M IN ATIO N
REFLEX
Right Left Interpretation
Physiologic
Biceps () ()
Triceps () () hypo reflex (+)
Knee () ()
Ankle () ()
Pathologic
Babinsky
Chaddock (-) (-)
Hoffman (-) (-)
Tromer (-) (-)
Pathologic reflex (-)
Openheim (-) (-)
No Primitive Reflex
Schaefer (-) (-)
Primitive Reflex (-) (-)
Palmomental (-) (-)
Snout
P H YSIC A L EX A M IN ATIO N
COORDINATION

Right Left Interpretation

Normal Normal
Not Not
Point to point
Tested Tested
movements
Not Not
Walk heel to toe
Tested Tested Cant be
Gait
Not Not assessed
Tandem
Tested Tested
Romberg
Not Not
Tested Tested
 P H YSIC A L EX A M IN ATIO N

AUTONOMY SYSTEM
Urination : Normal
Defecation : Normal

Others Examination
A.Laseque :>70 degrees
B.Kernig : >130 degrees
C.Patrick : -/-
D.Kontrapatrick : -/-
E.Valsava test : -
F.Brudzinski: -
P H YSIC A L EX A M IN ATIO N
THE SUMMARY OF EXAMINATION
General Status
Blood Pressure :110/80 mmHg
Heart Rate : 86 bpm
Respiratory Rate : 20 times per minute
Temperature : 36,8 C
Noble Function : Normal
Neck Stiffness : Negative

Cranial Nerves :Normal

Motoric :Tetraparese
Sensory :Normal
Coordination :Cant be assessed
Autonomy :Normal
Reflex :Normal
 W O R K IN G D IA G N O SE
CLINICAL DIAGNOSE
Tetraparese LMN Type

TOPICAL DIAGNOSE
Miogenic

ETIOLOGICAL DIAGNOSE
Hypokalaemic

DIFFERENTIAL DIAGNOSE
Myasthenia Gravis

SUGGESTION EXAMINATION
Blood routine
Electrolyte
Electrocardiography

MANAGEMENT
IVFD NaCl 0,9% 500 ml + KCl 25 mEq 20 dpm
Mecobalamin 2x1 IV
LABORATORY RESULTS

Blood Routine (January, 14th 2017)

Hemoglobin : 7,6 g/dL
Hematocrit : 23,2 %
Leukocyte : 17.880/mm3
Thrombocyte : 404.000/mm3

Electrolyt (January, 14th 2017)

Na+ : 134,1 mmol/L
K+ : 1,31 mmol/L
Cl++ : 77,4 mmol/L
Electrocardiography (January, 14 th 2017)

Rhythm : Sinus rhytm

Frequency : 100 x/minute
Axis : Normoaxis
PR Interval : Normal
ST segmen : Depressed ST in V4,V5
T flat : In all lead
FO LLO W U P
(January, 18th 2017)
S : The patient can move legs and arms
O :
GCS 15
Blood Pressure : 120/80 mmHg
Heart Rate : 86 bpm
Respiratory Rate : 20 tpm
Temperature : 36,8 C
Noble Function : Normal
Neck Stiffness: Negative
Cranial Nerves : Normal
Motoric : Normal
Sensory : Normal
Coordination: Cant be assessed
Autonomy : Normal urination and defecation
Reflex : Physiologic (+), Pathologic (-)
A : Hypokalaemic periodic paralysis
P :
- Patients is allowed to discharged from hospital
PERIODIC PARALYSIS
HYPOKALEMIC
D efi
nition

Periodic paralysis is a clinical syndrome with acute

weakness / paralysis that is more severe in childhood,
but if it happen in the third decade, the syndrome is
mild. The disease is largely hereditary and autosomal
dominant. Periodic paralysis will cause malfunctioning
ion channels in skeletal muscle membrane /
channelopathy
D efi
nition

General characteristics of periodic

paralysis primer as follows :
1. Is derived
2. Generally associated with changes
in serum potassium levels
3. Sometimes with myotonia
4. Periodic paralysis primer both due
to ion channel defect
EP ID EM IO LO G Y

The incidence of periodic paralysis hypokalemic

is about 1 in 100,000 people, men are more often
than women and usually heavier. The first age of
onset varies from 1-20 years, the highest
frequency of attacks is in the age 15-35 years
and then decreased by age.
Etiology and
Pathophysiology
1. Increased excretion (or loss) of potassium
2.Some medications can cause loss of potassium
and it will lead to hypokalemia.
3. Renal dysfunction Renal Tubular Acidosis
(RTA)
4. Loss of body fluids due to excessive vomiting,
diarrhea, or sweating..
5. Endocrine or hormonal problems
6. Poor dietary intake of potassium
D iagnose
Anamnesis and
symptoms

weakness and paralysis of the limbs are:

1. The weakness of skeletal muscles

2. Intermittent episodic
3. The attack came after sleep / rest and rarely
arises when exercise, but it may be triggered by
physical exercise
5. Muscles that often affected are the arms,
legs,shoulder and hip
6. in the legs usually occur much earlier than the
arm and often more severe than arm weakness,
and the proximal portion of the limb weakness
more apparent than the distal part
D iagnose
Anamnesis and
symptoms

Symptoms of the disease usually

occurs in puberty or more
Sensory system was still good
At the peak of the attacks, tendon
reflex was decreased
D iagnose
supporting investigation

Investigations such as blood labs in this case

blood electrolytes, ECG, hormonal levels,
urine, electromyography (EMG), and muscle
biopsy
Muscle weakness accompanied by low level of
potassium plasma (<3.0 mEq / L) and muscle
weakness improved after administration of
kalium
D iagnose
supporting investigation

Electrocardiographic abnormalities (ECG) that

can appear in the form of PPH flattening of the
T wave, ST segment suppression, U wave
apparent, ventricular fibrilation, arrhythmias,
supraventricular tachycardia, and block AV

Muscle biopsy showed normal results if there

is no attack , but at the time of the attack, it
can be found vacuolar myopathy
D if e
frential D iagnosis

Myasthenia gravis
is an autoimmune disorder characterized by
an abnormal and progressive weakness in the
skeletal muscles that are used continuously
and accompanied by fatigue during activity
D if e
frential D iagnosis
symptoms

Patients will feel very weak muscles in the day

and this weakness will be reduced if the
patient relax
Include weakness in the extraocular muscles
or ptosis
Paralysis of the oculomotor nerve, Bulbar
muscle weakness, difficulty swallowing and
speaking weakness of the muscles of the
pharynx, tongue, palate pallatum, and larynx
Therapy

PPH therapy involves giving oral potassium

started with 10-20 meq/L, given 2-4 times
daily (20-80 meq/hari)

Acetazolamide carbonic anhydrase

inhibitors, with usage dose 125-1500 mg / day
in divided dose
Prognoses

in untreated patients may develop weakness

proksimal settled, which could disturb activity

Some deaths have been reported, most

associated with aspiration pneumonia or
inability to remove slam
Thank you..