A 35yr old male with loss of sensation in both the lower limbs

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solveb those patient's clinical problems with collective current best evidence based inputs.




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


A 35 year old male with chief complaints of loss of sensation in both limbs below knee and palms since 6 months.


History of presenting illness:

Patient was apparently asymptomatic 4 years back. He then developed stomach pain where he got admitted to hospital when he got diagnosed as having high blood sugar as an incidental finding and started on oral hypoglycemic drugs then since 6 months he stopped taking medications for

 diabetes from then he develop polyphagia, polydypsia 

increased frequency of urination present 

delayed wound healing present weight loss present 

Tingling sensation of both upper limbs( palms)& lower limbs present

Loss of sensation present  

Numbness present 

No h/o headache ,vomitings

 


Daily routine

He wakes up in the morning at 6 am

Has his breakfast (rice)by 8am 

Goes to work at 9am

Has his lunch at 1pm

He goes back home by 8pm


Patient has been drinking alcohol since he was 15 years old.He starts his day by drinking alcohol.

He also chews tobacco and gutka

He also had alcohol withdrawal symptoms 


Past history:

K/C/o DM since 4 years -Stopped Medication since 6 months due to financial constraints

 Not a k/C/O HTN,TB, CAD,  Asthma, epilepsy



Personal history:

Diet: mixed

Sleep:adequate 

Apetite: decreased

Bowel and bladder: increased frequency 

Addictions: alcohol since he was 15 years old


GENERAL EXAMINATION:

Patient is conscious,coherent and cooperative, moderately built and moderately nourished.

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy: absent

Pedal edema: absent









VITALS:

Temperature: afebrile

Pulse: 86bpm

Blood pressure:120/80mm Hg

Respiratory rate: 18cpm


SYSTEMIC EXAMINATION:

CVS: S1 and S2 are heard

RS: trachea central  bilateral air entry present,NVBS,

Abdomen: soft and non tender,no organomegaly


CNS: higher mental functions intact

       

                                         Right.                       Left

Bulk:                               Normal                    Normal

Tone:

Upperlimb.                   Normal.                   Normal

Lowerlimb.                   Normal                    Normal 

Reflexes: biceps.             +.                              +   

                 Triceps.            +.                               +

                 Supinator.          +.                            +

                 Knee.                +.                             +

                 Ankle.                +                             +

                 Plantar             Flexion.                    Mute



Sensory examination 


Spinothalamic tract   


 Crude touch                            Right          Left


Upper limb                             Normal        Normal


Lower limb                        Decreased        Decreased 


Pain


Upper limb                            Normal         Normal 


Lower limb                            Decreased     Decreased 


Temperature 


Upper limb                            Normal          Normal 


Lower limb                            Decreased.    Decreased 


Posterior column


Fine touch


Upper limb                            Normal          Normal 


Lower limb                            Decreased.     Decreased 


Vibrations.                            Decreased.     Decreased  in lower limbs


Cortical 


Tactile localisation


Upper limb                            Normal          Normal 


Lower limb                            Decreased.     Decreased 


Stereognos 


Upper limb                            Normal          Normal 


meningeal signs absent







Provisional diagnosis:

Uncontrolled sugar secondary to non compliance to OHA
Alcohol dependence syndrome and tobacco dependence syndrome
Diabetic neuropathy 











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