Case of a 52 year old male patient

Hello! This is Likhita Maddula. A medical student. This is an e log that depicts patient centered learning medicine. This E-Log has been created after taking consent from the patient and their relatives.Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

July 07 2023

July 03 2023

Case of a 52 year old male patient

This is the case of a 52 year old male , farmer by occupation , resident of lingottam who presented to the hospital with chief complaints of 

- involuntary movements in his right leg from 8AM in the morning

- numbness of right leg since morning. 

History of presenting illness

The patient was apparently asymptomatic 15 years ago. He was a diagnosed with type 1 DIABETES MELLITUS 15 yrs ago and H/T 5yrs ago

- The patient was apparently asymptomatic 3 years ago when he noticed gangrenous foot which was developed secondary to trauma due to a thorn prick which had to be amputated after showing no signs of recovery. His ankle was spared but right 2,3,4 toes were amputated. 

- Bilateral weakness of both the lower Limbs which was Rapid in onset and involuntary movements were noticed by the patient 2 years ago

- His left leg was also amputated below the level of knee due to trauma from a bike fall which developed a non healing type of ulcer 3 months ago 

_ On medication for first 11 years and on insulin shots from past 4years for diabetes

- He noticed involuntary movements this morning at 8:00AM in his right leg which was rapid in onset and progressive in nature extending upto right half of trunk. These movements seemed to become more prominent on flexing his leg.numbness in the right leg was also felt. 

Not associated with pain and burning sensation.

No froth and tongue bite is seen.

Past history

N/k/c/o tb , epilepsy ,CAD asthma

Patient is a known case of

Type 1 Diabetes Mellitus since 15 yrs

 hypertension since 5 years

Been on medication for first eleven years after diagnosed,then shifted to insulin injections for the last four years.

Family history.

 his father is a known case of diabetes

Personal history

Mixed diet

Normal appetite 

Adequate sleep

Regular bowel movements

No Abnormal bladder movements 

 Was a chronic alcoholic 3 years back and reduced intake since then.

General examination. 

I have taken Prior consent of the patient and patient was examined in a well lit room.

Patient was conscious, coherent and cooperative.

No pallor ,icterus, clubbing ,cyanosis.

No generalised lymphadenopathy and bipedal edema.

VITALS:

Temperature- 98.6F

BP-130/80 mmhg

PR- 110bpm

RR-18cpm

Spo2-98%

No associated pain

SYSTEMIC EXAMINATION:

CVS- S1S2 heard and no murmurs heard.

R/s - bilateral expansion of chest and air entry.

P/a -tender soft

CNS examination:

Sensory system: normal

Motor system:

                                        Right Left

Tone- UL Normal Normal

                      LL Normal Normal

Power- UL 5/5 5/5

                      LL 4/5 4/5

Reflexes- Biceps +1 +1

                 Triceps +1 +1

                  Knee 0 0

                  Ankle 0 -

-loss of deep reflexes

-involuntary movements present

INVESTIGATIONS:

Chest x-ray:

ECG:

arterial Doppler:

He was diagnosed with peripheral vascular disease.

PROVISIONAL DIAGNOSIS:

Focal seizures with intact sensations.

Lower motor nerve lesion secondary to diabetic neuropathy.