70Y Male with B/L Upper and Lower limbs NUMBNESS & TINGLING sensation

Introduction: This is an online E-log Entry Blog to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs. 

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references. 

A 70 year old male, daily wage labourer presented to the General Medicine OPD with the 

CHIEF COMPLAINTS :

1. Tingling sensation in upper and lower limbs since 1 year. 

2. Bilateral upper and lower limb numbness since 1 year.

HISTORY OF PRESENTING ILLNESS:

1. Patient was apparently asymptomatic 1 year back then he developed tingling and numbness of upper and lower limbs, which was insidious in onset and gradually progressive. 
2. H/O polyphagia + , polydipsia + . No h/o nocturia 
3. C/O blurring of vision since 1 year (  IMSC )
4. No complaint of burning micturition, pain abdomen, loose stools.
5. No C/O chest pain, palpitations, shortness of breath. 

PAST HISTORY:

• Patient is a known case of Diabetes Mellitus type 2, since 1 year, on Tab Glimepiride 1mg, Tab Metformin 500mg. 
• Patient is a known case of Hypertension since 1 year, on medication Tab Amlong 5mg. 
• Patient is not a known case of Thyroid disorders, Seizures, Tuberculosis, Asthma, stroke or any cardiac disorder.
• No history of any previous surgeries.

PERSONAL HISTORY:

• His appetite in normal, he consumes a mixed diet, sleep is adequate. 
• Bowel and bladder movements regular and normal. 
• No history of smoking or alcohol.
• No known food or drug allergies.

FAMILY HISTORY:

• No similar complaints in the family members

GENERAL PHYSICAL EXAMINATION:

Examination has been done in a well lit room in supine and sitting posture after taking informed consent and after reassuring the patient.

• Patient was conscious, coherent, co-operative and well oriented to time, place and person.
• Moderately built and nourished.
• Pallor present.
• No signs of Icterus, Cyanosis, Clubbing, Generalized Lymphadenopathy.

Vitals:

14/06/2023

Temperature - Afebrile

Respiratory Rate - 17 cpm

Pulse Rate - 88 bpm

Blood Pressure - 130/80 mm Hg

SpO2 - 99 at room air 

SYSTEMIC EXAMINATION:

Cardiovascular system: S1, S2 heard. No murmurs heard. 

Central Nervous System: No abnormality detected.

Per Abdomen : Scaphoid shape, Soft and non-tender, no palpable masses, No liver/spleen palpable, bowel sounds heard 

Respiratory System: Bilateral air entry +, Normal vesicular breath sounds heard

INVESTIGATIONS:

14/06/2023 

RBS: 145mg/dl

Blood Urea: 24mg/dl

Serum Creatinine: 0.8mg/dl         Utica Acid: 4.5 mg%

Total Proteins: 6.3 gm/dl 

AST: 35 IU/L      ALT: 45 IU/L     ALP: 163 IU/L

Albumin: 3.8 gm/dl     A/G ratio: 1.54

TB: 0.96 mg/dl            DB: 0.18mg/dl 

PROVISIONAL DIAGNOSIS:

Diabetic Neuropathy ( with DM type 2 since 1 year and HTN since 1 year ) with B/L Osteoarthritis Knee. 

TREATMENT:

1. Tab AMLONG 5mg PO/OD

2. Tab GLIMEPIRIDE 1mg PO/BD

3. Tab METFORMIN 500mg PO/BD 

4. Tab PREGABALIN 75 mg PO/HS + Tab Methylcobalamin

5. Monitor vitals - BP, RR, PR, Temperature 

Questions for this case: 

1. What is the cause for numbness in this patient?