36M with diabetic neuropathy

 

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

C/o

Weakness in both upper and lower limbs since 6months

Slurring of speech since 5 years

Hopi:

Patient is apparently symptomatic 5 years back then he developed stiffness in neak 

And headache while carrying heavy weights on his head as his daily routine work . After 1 year he developed progressive weakness in arms and reached to a stage where he couldn’t lift a glass of water( according to patient). Weakness progressed to lower limbs in 1 year reached to a stage where he couldn’t get up if he sat on the floor. I/V/O above complaints the patient went to hospital in Hyderabad there they advised MRI c spine- early degeneration of cervical spine.

CT brain-mild Diffuse cerebral atrophy.

10 years ago the patient had chickengunya he was admitted and treated symptomatically.

Past history 

N/k/c/o HTN DM ASTHMA EPILESY TB

Personal history

Married

Occupation daily labourer

Addictions- whisky 90 ml 6-7 years

General examination

Patient is conscious coherent cooperative 

No  PICKLE

Vitals

BP -120/80 mmhg

Pulse-82 bpm

RR- 19 cpm

Temperature- afebrile

Spo2 98 percent 

CVS- S1S2+

RS- BLAE+

P/A-nontender soft

CNS examination 

Higher mental functions 

Orientation to place , person , time+

Memory - immediate, short , long+

Pupils-NSRL

Speech- slurred

Cranial nerve examination 

Cn1 - intact

CN2-intact

CN3-intact

CN4-intact

CN5-intact

CN6-intact

CN7-intact

CN8-intact

CN9-intact

CN10- intact

CN11-intact

CN12-intact

Motor system

                 Rt.          Lt

Bulk.  UL normal.   Normal

           LL. Normal         Normal 

Tone. UL normal.     Normal

           LL. normal.    Normal

Power

 UL

  Arm       5/5.           5/5

Forearm. 5/5.           5/5

Wrist.       2/5.         2/5

Finger.      2/5.          2/5

LL

Hip.         5/5.        5/5

Thigh       5/5.         5/5

Calf.        5/5.          5/5

Reflexes.      B.   T.    S.    K.    A.   P

Right.           -      -      -     -     -      Flexion

Left.              -     -      -      -     -      Flexion

Cerebellar signs 

Finger nose test - coordination present

Finger finger test- coordination present

Rombergs test- + , swaying to right

Dysdiadochinesia- intact

Sensory 

Crude touch pain temperature- normal

Position , finetouch, vibration- normal

Graphetesia , steriognosis- normal

Investigations

Babinski sign

Dysdiadochinesia

Rhomberg test

Biceps 

Treatment given

Inj. OPTINEURON 1 amp in 500ml NS

Tab. MUT PO/OD