54 F came with Diabetes for 3 years, weight loss of 8 to 10kgs in a year b/l tingling sensation in upper and lower limbs

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Dr. Sarbesh Mishra

Roll no.: 142


54 year old female came with c/o Diabetes for 3 years, weight loss of 8 to 10kgs in a year b/l tingling sensation in upper and lower limbs 


HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 1 year back , then the patient had developed tingling and numbness in the B/L upper and lower limbs 

Tingling started in the foot and palm and gradually progressed to B/L legs and hands.

No history of loss of sensation 

No history of trauma / fall 

History of polyuria + 

No history of polyphagia and polydypsia 

History of weight loss of 8 to 10 kgs in a year 

No history of fever,cough, vomiting, 

Burning micturition, shortness of breath , pedal edema and Giddiness 


PAST HISTORY:-

No similar complaints in the past (before 1 years) 

Known case of DM type 2 (+)since 3 years used medication for 2and half years Stopped the medication 6months back 

Known case of HTN (+) since 8 years used medication for 6 years stopped the medication 2 years back

Not a know case of TB , bronchial asthma, epilepsy, CAD, thyroid.


SURGICAL HISTORY:- 

She underwent a LSCS 33 years ago 


FAMILY HISTORY:-

 No family history of HTN, DM, bronchial asthma, epilepsy


PERSONAL HISTORY:-

Diet: Mixed

Appetite: Normal

Sleep: Normal

Bowel: regular

Bladder: normal

Habits : She has no addictions what so ever 

No alcohol and no smoking habits 


SOCIAL HISTORY AND DAILY ROUTINE:-

She is a house keeper by occupation 

Married and has a child (boy) 

Everyday she wakes up around 6am and starts preparing breakfast for her family

In breakfast she usually have puffed rice, Dall with rice and every one in her family have the same breakfast routine.

At around 11am she again eats the same food that is Dall with rice and sometimes added up with non veg food (chicken and mutton)

At 12pm she prepares lunch again for her family ..... 

Usually she prepares rice and mixed vegetables curry

And around 3pm she again has the lunch in a little bit quantity

Every day in the evening at around 6pm she has a drink which includes lemonade( non sweetened ) and Fenugreek seed (methi) or fennel seed (saunf) soaked in water the day earlier 

Its her daily practice and someone told her that drinks that's she is having might cure her diabetes and she following it since 2 years 

She goes for walk for around 3kms every single day in the Evening and returns back home and takes a bit rest for an hour while she goes to her kitchen for preparing the dinner 

As usually she prepares rice and Dal mixed with vegetables or non veg according to their taste of interest 

She doesn't take any food in the dinner neither chapati nor rice because she feels undigested

So she has the same puffed rice for the dinner that was made in the morning for her and her family , she complained about polyuria (6 to 7 times per day) and nocturia to her husband and her husband took her to a local hospital that's when she was diagnosed with diabetes 

When her husband finds out that she gets angry and tensed on simple issues that happen at home and took her to the local hospital thats when she was diagnosed with hypertension and she said it ranges around 150/90 to 170/100, She said she stopped having medication for both the diabetes and hypertension because she feels like the medication she is taking doens't cure her diabetes or hypertension  

But she takes medication for diabetes whenever she feels like the nocturia is increased ........



GENERAL EXAMINATION:

The patient was examined after taking consent in a well lit room

Patient is conscious,coherent , cooperative, 

Oriented to time , place and person

She is moderately built and nourished 

Pallor: Absent

Icterus: Absent

Cyanosis: Absent

Clubbing: Absent

Lymphadenopathy: Absent 

Edema: Absent  


Vitals:

PR: 84 BPM

RR: 16 cpm

BP: 120/70mmHg

SpO2: 98%

Temperature: 98.4°F

GRBS: 180 mg/dl


CLINICAL IMAGES:







SYSTEMIC EXAMINATION:


CVS:

On inspection: 

Precordium is normal

Apex impulse could not be seen

No visible pulsations

On palpation:

Apex beat localised to 5th intercostal space medial to mid clavicular line.

No parasternal heave

No palpable thrills

On auscultation:

S1 and S2 heard.

No cardiac murmurs heard.


RS:

On inspection:

Chest shape is elliptical

Expands equally on inspiration

Trachea: central

On palpation: 

Tactile vocal fremitus is equal in all areas

On percussion:

Resonant note on all regions.

On auscultation: 

Bilateral air entry positive

Vesicular breath sounds are heard.

No adventitious sounds such as crepts, rochi, etc heard.


ABDOMEN:

On inspection

Abdomen is scaphoid.

Umbilicus is central and inverted

No scars or sinuses

On palpation:

Abdomen is soft

No tenderness

No organomegally.

On auscultation:

Bowel sounds heard.


CNS:

Cerebellar functions normal

Cranial nerve examination normal

Sensory examination: normal

Motor examination:

                                  R. L

Tone: 

                           UL. N. N 

                           LL. N. N

Power:

                           UL. 5/5 5/5 

                           LL. 5/5 5/5


Reflexes:

     Biceps.                ++. ++

     Triceps.              ++. ++

     Knee.                  ++. ++

     Ankle.                   +.+


INVESTIGATIONS:




PROVISIONAL DIAGNOSIS:
? DIABETIC NEUROPATHY 
? PERIPHERAL NEUROPATHY WITH DIABETES TYPE 2 

TREATMENT:
1) Tab GLIMI M1 PO/OD 
2) Tab PREGABALIN 75 PO/OD


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