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Abhignya
Roll.No.83
Case:
This is a case of a 35 year old male with chief complaints of loss of sensation in both limbs below knee and upper limbs below elbows since 6 months.
Daily routine- patient is a labourer by occupation.
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 has a habit of drinking throughout the day.
He also chews tobacco.
History of presenting illness:
Patient was apparently asymptomatic 4 years back. He then developed stomach pain for which he got admitted in a hospital where he was 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 & lower limbs present
Loss of sensation present
Numbness present
No Burning micturition
Loss & sensation initially present in B/L feet which progressed to below knees since he stopped medication
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
Apetite: decreased
Bowel and bladder: increased frequency
Addictions: alcoholic since he was 15 years old
And used to drink throughout the day
Chews tobbaco
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: 98 degree farenheit
Pulse: 90 beats/minute
Blood pressure:120/70mm Hg
Respiratory rate: 16cpm
GRBS-520mg/dl
Spo2 -99% at RA
SYSTEMIC EXAMINATION:
CVS: S1 and S2 are heard,no murmurs
RS: bilateral air entry present,NVBS
Abdomen: soft and non tender
CNS: higher mental functions intact
Right. Left
Reflexes: biceps. +. +
Triceps. +. +
Supinator. +. +
Knee. +. +
Ankle. + +
Plantar Flexion. Mute
Investigations:
UNCONTROLLED SUGARS SECONDARY TO NON COMPLAINCE TO OHA WITH ALCOHOL DEPENDENCE SYNDROME AND TOBACCO DEPENDENCE SYNDROME
WITH DIABETIC POLYNEUROPATHY
WITH DIABETIC ULCER OVER RIGHT FOOT
K/C/O DM TYPE 2 since 4 years
Treatment:
IV FLUIDS NS@ 75 ml/hr
INJ.THIAMINE 200mg in 100ml NS iv/OD 8am
INJ.OPTINEURON IN 100ml NS/IV/OD
Inj. NPH s/c BD according to GRBS
INJ.HUMAN ACTRAPID INSULIN SC/TID ACCORDING TO GRBS
GRBS MONITORING 4th HRLY
I/O CHARTING
STRICT DIABETIC DIET
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