35 yr old male with loss of sensation in both lower limbs below knee

 

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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

B.RISHIKA SRI

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