60 years male with tingling sensation in limbs

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A 60 year old male resident of  nalgonda  came to casualty at 3.00 pm  on 5th December,  2022.

CHIEF COMPLAINTS:-

Tingling and numbness of both upper and lower limbs since 5 years.

Headache and vertigo from 1year.

Weakness of lower limbs since 7 days.

HISTORY OF PRESENTING ILLNESS:-

 Patient was apparently asymptomatic 10 years back then he got electric current  shock on the right side of leg above knee. Then he went to local RMP and was given some medication.

Then 5 years back , he complained of tingling sensation and numbness in the right leg .

3 years back his son observed that he was speaking irrelevant , had blurring of vision for which they went to hospital and they were said that there was some clot in the brain on the left side.(no documents available)

18 months back he developed tingling sensation and  numbness in the left leg .

1 year back he started having headache which is associated with vertigo which is insidious in onset and gradually progressive relieved on medication.

1 month back he also started developing numbness and tingling sensation in both palms.

7 days back he complained of weakness of Lowerlimb.

There was no sensations present in both lower limbs.

No deviation of mouth, difficulty in swallowing.

PAST HISTORY:-

Known case of Diabetes since 4 years and is on medication using • glycomet gp 

History of CVA

Known case of vertigo and on medication 

Not a Known case of hypertension, asthma, TB, epilepsy.

Not a Known case of CAD.

PERSONAL HISTORY:-

 Appetite:-normal

Bowel and bladder :-regular

Diet:-mixed

Sleep:-adequate.

Addictions:-

intake of alcohol of 90 ml per day

Bidi 1 packet per day

Allergies:-nil

Family history:-no significant family history.

GENERAL EXAMINATION:-

Patient is conscious, coherent, cooperative and well oriented to time , place and person, moderately built and moderately nourished.

No pallor

  

No icterus 

No cyanosis

No clubbing

No lymphadenopathy 

No edema.

Vitals :- 

Temperature:- afebrile

RR:-18cpm

BP:-130/80 mmhg

HR:- 110bpm

  

SYSTEMIC EXAMINATION:-

CNS:-

Higher mental functions intact.

Gait:- normal

●CRANIAL NERVES: INTACT

•Power

Rt UL-5/5. Lt UL-5/5 

Rt LL-4/5. Lt LL-4/5 

•Tone-

Rt UL -N,Lt UL-N

Rt LL-N,Lt LL-N

Reflexes:. RIGHT LEFT

           Biceps ++ ++

           Triceps ++ ++

        Supinator ++ ++

                Knee. -- --

               Ankle:- -- -- 

•SENSORY

crude touch :normal in upper limbs and lower limbs 

Pain sensation present

Vibration not felt

Joint position he is unable to tell

Rombergs test positive falling on right side 

Cerebellum functions:-

Finger finger test:- positive 

Finger nose test:- positive 

Dysdiadokinesia:-not present

Heel knee test:-negative

Straight leg walking test:- positive

ABDOMEN EXAMINATION:

•Inspection :- no scars

•Palpation :- soft,non tender

Auscultation:bowel sounds heard 

CVS:S1,S2 heard,no murmurs

RESPIRATORY SYSTEM:

•trachea central in position

•Normal vesicular breath sounds heard

•BAE ++

Provisional diagnosis:-

Peripheral neuropathy secondary to diabetes?

INVESTIGATIONS:-

  Report on 06/12/ 2022 

LIVER FUNCTIONAL TESTS

SERUM CREATININE

SERUM ELECTROLYTES

                              HEMOGRAM

ECG:-

USG :- 

Colour Doppler 2D echo :-

Xray:-

PREVIOUS :

Treatment:- 

1. Strict diabetic diet

2. Tab. Glycomet gp 

3. Tab. Vertin 

4. Monitor vitals Ruth hourly 

5. GRBS charting

6. Collect reports 

7. Tab. Pregabun