55 yr /M with Diabetic Neuropathy?? With lumbar spondylosis K/c/o HTN, DM

 55 Yr /M  resident of Nalgonda came to the opd with  Cheif complaints of

C/o : Burning sensation of soles: 5 _ 6 yrs

C/o Generalised weakness : 3 _4 yrs

C/o weakness in lower limbs: 2 yrs

C/o loss of sensation of lower limb : 2 yrs

HOPI

Patient was apparently asymptomatic 6 yrs back then he developed burning sensation of soles since 6 yrs and generalised  weakness has aggravated  in the lower limbs  since 6 months. 

Patient was unable to do his routine daily activities and started walking with support since 1 month. Along with with loss of sensation of the lower limbs since 2 to 3 yrs which started in the soles and progressed  up to knees. 

Patient started wearing shoes instead of slippers since 2 to 3 yrs as there was slip of footwear. 

Neurosurgery opinion was taken and advised MRL-LS spine. (Lumbar spondylosis L3 _S1) was advised to take neurophysician opinion. 

Neurophysician opinion : No active intervention needed. Advised glycemic control. 

Past H/o:

K/c /0 HTN , DM :8 yr

N/k/c/o Asthma, TB, epilepsy, CAD. 


PERSONAL HISTORY :-


Marital status : married 

Occupation:Stopped working since 2 yrs. 

Diet : mixed 

Appetite : normal

Bowel and bladder: regular

Sleep : adequate

Addictions : 

Occasional alcoholic since 14 yrs


GENERAL EXAMINATION:-


Patient was concious coherent cooperative well built and nourished , well oriented to time place and person at the time of presentation.

Pallor : present

Icterus : absent

Cyanosis : absent 

Clubbing : present

Lymphadenopathy : absent 

Edema : absent







VITALS

Temp:98F

PR : 82bpm

BP : 110/70 mm Hg

RR : 16cpm

Spo2: 98 on RA

GRBS : 103 mg/dl


SYSTEMIC EXAMINATION:-

I) Per Abdomen :


INSPECTION :-


Shape of abdomen -Flat

Umbilicus - inverted

No scars, sinuses, straie

No visible pulsations & visible peristalsis

Movements of all 4 quadrants moving equally with respiration


PALPATION :-

All inspectory findings are confirmed

No local rise of temperature

Tenderness present in the epigastric region

No palpable mass present

No palpable lymphadenopathy

No organomegaly

Hernial orificies - Free


PERCUSSION :-

No signs of fluid thrill & shifting dullness

Resonant note heard (except liver dullness)


AUSCULTATION :-

Bowel sounds present

No bruit heard


CNS:-

HIGHER MENTAL FUNCTIONS:

Oriented to time place and person 
Immediate memory:Intact
Short term memory:Intact
Longterm memory:Intact
No delusions and hallucinations.

Sensory system:

Spinothalamic tract

                                            R                    L
Fine touch 
    
Upper limb                 Present          Present
Lower Limb               A(L4_S1)         A(L4_S1) 

Pain

Upper limb                Present             Present
Lower Limb               Present             Present

 Temperature

Upper limb                 Present              Present
Lower Limb                Present              Present

Dorsal column

Vibration
  
Styloid process            3.02 sec               5.4 sec

Proprioception

Olecreanon                  7.04 sec                11.2 sec

Shoulder                       9.12 sec                 8.42 sec

Medial malleolus           Absent                 Absent

Tibial tuberosity             Absent                 Absent

Cortical Sensations:

2 point discrimination  in dorsum of fingers

Upper limb                  present                  present 

Lower limb                   absent                   absent

Graphaesthesia             N                            N

Stereognosis                   N                           N

  

Motor system

Power:-

Upper limb                     5/5                           5/5


Lower Limb                    5/5                         5/5


Tone:-


Rt UL - normal

Lt LL- normal

Rt LL- normal

Lt LL- normal


Reflexes: 

                   Right                    Left

Biceps:      +++                    +++

Triceps:       ++                  ++

Supinator:   +                   +

Knee:            -                     -

Ankle:            +                 +

Plantar:       -                        -


CVS:-

S1S2 heard

no murmurs.

Respiratory system examination

Bilateral air entry present.

Normal vesicular breath sounds present.


















Provisional Diagnosis:

Diabetic Neuropathy with Lumbar spondylosis  

Treatment

Inj. Optineuron 1 Amp in 100 ml NS IV OF

Tab. Clinidipine  10mg + Chlorthalidone 12.5 mg+ metoprolol 50 mg PO OD

Tab. Sitagliptin50mg + metformin 500mg

Cap. Gabantin 100mg PO BD

Tab. Orofer XT po 


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