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60yr old male with numbness and tingling of limbs



 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


 Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 
 This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment .
A 60 year old male resident of  nalgonda  came to casualty at 3.00 pm  on 5th December,  2022.


CHIEF COMPLAINTS:-
Tingling and numbness of both upper and lower limbs since 5 years.
Weakness of lower limbs since 5 days.

HISTORY OF PRESENTING ILLNESS:-
 Patient was apparently asymptomatic 10 years back then he got shock  due to electric current  on the right side of leg above knee. Then he went to local RMP and was given some medication.

Then 5 years back , he complained of tingling and numbness in the right leg .
3 years back his son observed that he was speaking nonrelevantly , had blurring of vision for which they went to hospital and they were said that there was some clot in the brain on the left side.(no documents available)

18 months back he developed tingling and  numbness in the left leg .
1 month back he also started developing numbness and tingling in both palms.
5 days back he complained of weakness of 
Lowerlimb.
There was no sensations present in both lower limbs.
No deviation of mouth, difficulty in swallowing.

PAST HISTORY:-
Known case of Diabetes since 4 years and is on medication 
History of CVA
Not a Known case of hypertension, asthma, TB, epilepsy.
Not a Known case of CAD.


PERSONAL HISTORY:-
 Appetite:-normal
Bowel and bladder :-regular
Diet:-mixed
Sleep:-adequate.
Addictions:-
intake of alcohol of 90 ml per day
Cigarette 1 packet per day
Allergies:-nil

Family history:-no significant family history.


GENERAL EXAMINATION:-
Patient is conscious, coherent, cooperative and well oriented to time , place and person, moderately built and moderately nourished.
No pallor
  



No icterus 
No cyanosis
No clubbing
No lymphadenopathy 
No edema.
Vitals :- 
Temperature:- afebrile
RR:-18cpm
BP:-130/80 mmhg
HR:- 110bpm
  
SYSTEMIC EXAMINATION:-
CNS:-
Higher mental functions intact.
Gait:- normal
●CRANIAL NERVES: INTACT

•Power

Rt UL-5/5. Lt UL-5/5 

Rt LL-4/5. Lt LL-4/5 

•Tone-

Rt UL -N,Lt UL-N

Rt LL-N,Lt LL-N

Reflexes:. RIGHT LEFT

           Biceps ++ ++

           Triceps ++ ++

        Supinator ++ ++

                Knee. -- --

               Ankle:- -- -- 


•SENSORY

crude touch :normal in upper limbs
decreased in lower limbs 

Pain sensation present
Vibration not felt
Joint position video he is unable to tell
Rombergs test positive falling on right side 



Cerebellum functions:-
Finger finger test:-+
Finger nose test:-+
Dysdiadokinesia:-not present
Heel knee test:-negative
Straight leg walking test:- positive

ABDOMEN EXAMINATION:

•Inspection :- no scars

•Palpation :- soft,non tender

CVS:S1,S2 heard,no murmurs

RESPIRATORY SYSTEM:

•trachea central in position

•Normal vesicular breath sounds heard

•BAE ++

Provisional diagnosis:-
Peripheral neuropathy under evaluation?

INVESTIGATIONS:-
  Report on 05/12/ 2022 

LIVER FUNCTIONAL TESTS



SERUM CREATININE


SERUM ELECTROLYTES




                              HEMOGRAM




ECG:-


Xray:-

PREVIOUS :


  




creati treatment:-
• glycomet gp
• vertin 16mg

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