60F with chief complaints of tingling and numbness of lower limbs

Hi!! This is Vijaya ratna,9th semester medical student. This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

A 60 year old female patient agricultural worker by occupation,resident of kodad came to general medicine department with C/o Tingling and numbness of both lower limbs from ankle to calf muscles since 1 year

       

HOPI

patient was apparently asymptomatic 10 months back,then she had tingling sensation and numbness of lower limbs from ankle to calf muscles which  was insidious in onset,gradually progressive and lost sensation of foot. 

She was taken to khammam private hospital with similar complaints,taken medication but not relieved

C/o Shortness of breath while walking few steps and stops for some time to take breath with no aggravating and relieving factors

Nocturia present

Polyphagia present

Polyuria absent

No c/o chest pain, palpitations, orthpnea and paroxysmal noturnal dysuria

No c/o burning micturition

No c/o fever,cough and cold

Past history

K/c/o diabetes since 30 years

K/c/o bronchial asthma since 30 years

K/c/o hypertension since 1 month

K/c/o CKD since 1 month

N/K/c/o epilepsy,TB

TREATMENT HISTORY

Drug history

Tab.Metformin 500mg three times a day for diabetes since 30 years

Levosalbutamol for bronchial asthma since 30 years and budesonide since 1 month

Tab.losartan  for hypertension since 1 month

Past surgical history

Tubectomised 30 years back

Hysterectomy  20 years back

PERSONAL HISTORY

Patient takes mixed diet

Appetite decreased

Regular bowel and bladder movements

Sleep disturbed due to tingling and burning sensation of feet

Addictions -  toddy drinker

FAMILY HISTORY

no significant family history 

ALLERGIC HISTORY

no allergies to any kind of drugs or food items

GENERAL EXAMINATION

Patient is conscious, coherent, and cooperative 

Moderately built and nourished

Pallor present

No icterus 

No cyanosis 

No clubbing

No lymphadenopathy

VITALS:

Temperature - Afebrile

Pulse Rate - 88 bpm

Respiratory Rate - 16cpm

Blood Pressure - 110/70mmHg

Sp02 - 99% at Room air

GRBS - 344 mg/dl

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

S1 ,S2 heard,no murmurs,no thrills

RESPIRATORY SYSTEM

INSPECTION

Bilateral Air entry Present

Trachea- central 

Movements of Chest decreased on left side

Type of respiration- thoracoabdominal

PALPATION

All inspectory findings confirmed by Palpation 

Expansion of chest- normal

Tactile vocal fremitus - normal

PERCUSSION:

 

                          RIGHT               LEFT         

Supra clavicular: resonant     resonant

Infra clavicular: resonant      resonant 

Mammary: resonant            resonant 

Inframammary resonant      resonant 

Axillary:    resonant            resonant 

Infra axillary: resonant.      resonant

Supra scapular: resonant   resonant 

Infra scapular: resonant     dullnote

Inter scapular: resonant        resonant 

AUSCULTATION

Vocal resonance normal on both sides

Normal vesicular breath sounds heard

PER ABDOMEN EXAMINATION:

INSPECTION 

Abdomen Shape Obese

Umbilicus is central in position

PALPATION 

No Tenderness on palpation.

Temperature - Afebrile

Liver is Non palpable

Spleen is Non palpable

PERCUSSION: tympanic note 

AUSCULTATION Bowel Sounds Heard

CENTRAL NERVOUS SYSTEM 

Patient is conscious coherent and cooperative

Speech is normal 

No signs of meningeal irritation

Cranial nerves - intact 

Motor system:

                 Right      Left 

 Bulk UL        n         n      

        LL         n         n

Tone UL        n         n 

        LL        n         n 

Power UL      5/5    5/5 

         LL       5/5      5/5 

Reflexes

Superficial reflexes: present

Corneal 

Conjunctival 

Abdominal 

Plantar reflexes 

Deep reflexes:Present

        Right      Left

Bicep ++           ++

Triceps +       +

Supinator +   +

Knee ++            ++

Ankle ++          ++

Co ordination present 

Gait normal 

No involuntary movements 

Sensory system

Pain, temperature, pressure, vibration perceived 

Romberg's test:absent

Graphaesthesia:normal 

Cerebellar signs: 

No nystagmus

Finger nose test positive

Heel knee test positive 

INVESTIGATIONS 

PROVISIONAL DIAGNOSIS

DIABETIC PERIPHERAL NEUROPATHY WITH KNOWN CASE OF DIABETES,BRONCHIAL ASTHMA , HYPERTENSION AND CKD

TREATMENT

14/10/23

Nebulisation Duolin 6th hourly

                   Budesonide 12th hourly

Tab Losartan 50 mg po/oD

Tab metformin 500mg PO/BD

GRBS PROFILE

 

15/10/23

Inj.human actrapid insulin s/c TID before meals

Nebulisation Duolin 6th hourly

                   Budesonide 12th hourly

Tab Losartan 50 mg po/oD

Tab metformin 500mg PO/BD

GRBS PROFILE

16/10/23

Inj.human actrapid insulin s/c TID before meals

Inj.Lasix 40 mg PO/OD

Tab.Nodosis 500mg PO/OD

Tab.Shelcal PO/OD

Nebulisation Duolin 6th hourly

                   Budesonide 12th hourly

Tab Losartan 50 mg po/oD

Tab metformin 500mg PO/BD

GRBS  2nd hourly monitoring 

18/10/23

Inj.human actrapid insulin s/c TID before meals

Tab.Nodosis 500mg PO/OD

Tab Losartan 50 mg po/oD

Inj.Lasix 40 mg IV/BD