A 35 year old male with loss of sensation of the limbs

 

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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 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 & 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: 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: 98 degree farenheit

Pulse: 90 beats/minute

Blood pressure:120/80mm Hg

Respiratory rate: 20 cpm

SYSTEMIC EXAMINATION:

CVS: S1 and S2 are heard

RS: bilateral air entry present

Abdomen: soft and non tender

CNS: higher mental functions intact

       

                                         Right.                       Left

Reflexes: biceps.             +.                              +   

                 Triceps.            +.                               +

                 Supinator.          +.                            +

                 Knee.                +.                             +

                 Ankle.                +                             +

                 Plantar             Flexion.                    Mute

Investigations:

Provisional Diagnosis:

Uncontrolled sugar secondary to non compliance to OHA

Alcohol dependence syndrome and tobacco dependence syndrome

Diabetic polyneuropathy

Treatment:

1) IV 1) IV Fluids NS @ 75 mIl he

2) INJ THIAmINE 200mg in l00M, NIS
8Am -28m - 8Pm

3) INS OPTINEUROM in 100ML