A 55 YEAR OLD MALE WITH UNCONTROLLED SUGARS

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 box"
Unit 2 new admission in M - Ward.


A 55 years old male, farmer by occupation,presented to OPD with chief complaints of

1)tingling and numbness of both lower limbs since 6 months
2)generalised weakness and bodypains since 6 mnths
3)Slippage of footwear since 6 months associated with loss of sensation of both foot since 6 months.

HOPI:patient was apparently normal 6-7 years back then on one fine day in 2016 he noticed raised skin lesions filled with fluid(?bullae) and provisionally diagnosed as bullous pemphigoid .

In 2017, December patient had bilateral lower limb swelling associated with SOB on exertion as his neighbours suggested he went to NIMS, where kidney biopsy was done and diagnosed as CHRONIC GLOMERULONEPHRITIS(Biopsy report missing) and started on conservative treatment for CKD, in view of elevated uric acid,patient was then started on FEBUXOSTAT 40 mg OD, creatinine then was 1.5. 

In april 2018, patient had sudden involuntary moments of left UL and LL,not associated with LOC.with an abscess on Left forearm then RBS was 893mg/dL and diagonosed with ?DIABETIC CHOREA/?HONK(urine ketone bodies absent) and for the fisrt time patient was diagnosed with diabetes & HTN  started on insulin mixtard(70:30) 20-*-18 and Linagliptin 5mg OD

In sep 2018,uric acid:10.1, creatinine:1.8, TSH:6.1 

In NoV 2018, patient went for routine follow up and then diagnosed with hypothyroid with TSH 8.1 and started on thyronormb12.5mcg/OD and then HBA1c 5.9 and uric acid 10.2

In jan 2019 patient met with accident and had injury over right foot which was not healing for 2 months then in march 2019, patient went to NIMS,for delayed healing of ulcer,debridememt was done and then HBA1C 9.4, triglycerides:620;FBS 250;PLBS:439. uric acid 10.1, then patient was given Inj.Human actrapid insulin 15—12—10, inj.Lantus 10 units night.

Now since 6 months, patient had tingling and numbness of both LL till ankle and hands associated with slippage of footwear and loss of touch and pain sensation of Bilateral foot.


On examination : 

Patient is conscious , coherent, co operative

Afebrile
Bp -130/80 mmhg
PR-90bpm
SPO2 - 98%@ RA
RR-18cpm

No Pallor,icterus,cyanosis,clubbing,edema 


CVS - No visible scars ,Apex beat @ 5th ICS medial to mid clavicular line, S1 & S2 heard 

P/A - soft & nontender

CNS : 


                                  Right                Left

Bulk :                
      Upper limb         Normal            Normal   .         
    Lower limb .        Normal.           Normal

Tone: 
      Upper limb:.     Normal.         Normal
      Lower limb:.     Normal.        Mild Hypotonia

Power:
      Upper limb:.     4/5.               3/5
      Lower limb:.     4/5.                3/5
Hand grip :             100% .           Reduced
 following commands
 
Motor system 
Reflexes:  
  
   Deep tendon reflexes: 
      Biceps:.            3+                 3+
      Triceps:.           3+                 3+
      Supinator:.       3+                3+
      Knee:.                3+                3+
      Ankle:.                -.                 -
      Plantar:.           Mute            mute

Sensory system: 

                                        right LL         Left LL
                 
        Fine touch               Absent        Absent
        Vibration                   intact.        Absent
        Position sense        Absent        Absent
       Crude touch            Absent        Absent
       pain ( below knee) Absent        Absent
       Temp                        Absent.       Absent
       
( mild cold - cool vial from ICU fridge - comparator case 1 PDCC young diabetic and pt attender, examiner )

Rhomberg's - swaying present

Cerebellum: 
Nystagmus absent
Dysdiadochokinesia - Difficulty in doing.
Heel shin - delayed and doing cautiously









Cranial nerve examination:
  I : intact
II : Colour vision normal
III,IV,VI : normal pupil size
                No nystagmus,ptosis,eyemovements normal
V: Sensory - normal
    Motor - normal
Corneal & conjunctival reflexes - normal

Vll: No Deviation of angle of mouth towards right, Able to close eyes.
frowning present on both sides of forehead 

VIII : normal.
IX,X: Uvula- visualised,gag reflex + 
XI: normal
XII: tongue- tone normal,no deviation

ANS:  Regular bladder movements. No sweating and palpitations 
Autonomic nervous system
Investigation
FBS-391
Serology - Negative
Urinary Electrolyte
Na- 118
K-8
Cl-174

Spot urine protein -134.2->60
Spot urine creatinine-76.7->68.2
Ratio-1.74-> 0.88

urine for ketones - negative
Serum electrolytes 
Na-136
K-3.3
Cl-101

TC -176->174
TGL-886->712
HDL-38.8->58
LDL-108->113


X ray of c- spine
Usg of abdomen
Fundoscopy

 Provisional Diagnosis : 
Diabetic Nephropathy with Diabetic peripheral neuropathy with left quadriparesis 

Treatment:
1) TAB.THYRONORM 25mcg PO/OD
2) TAB. OLMESARTAN-H 40mg PO
3) TAB. NODOSIS 500 mg PO/OD
4) TAB.SHELCAL 500mg PO /OD
5) INJ HAI S/C TID  According to GRBS S/S
6)INJ OPTINEURON 1 amp in 100ml Ns IV /OD
7)TAB .FEBUXOSTAT 40mg PO/OD
8) TAB BIO-D3 PO/OD
 
13/4/22
S - No new complaints
O- patient is conscious, coherent, cooperative 
Vitals
Bp-100/90 mmhg
PR-90bpm
SpO2- 98%,@ RA
Temp-97.6F
CVS - S1,S2 +
RD - BAE +
A-CKD SECONDARY TO DIABETIC NEPHROPATHY WITH ? DIABETIC PERIPHERAL NEUROPATHY WITH HTN/DM/HYPOTHYROIDISM/CKD/?CAD WITH LEFT QUADRIPARESIS SECONDARY TO CERVICAL MYELOPATHY
P- Planning for fundoscopy for diabetic retinopathy
1) TAB.THYRONORM 25mcg PO/OD
2) TAB. OLMESARTAN-H 40mg PO
3) TAB. NODOSIS 500 mg PO/OD
4) TAB.SHELCAL 500mg PO /OD
5) INJ HAI S/C TID  According to GRBS S/S
6)INJ OPTINEURON 1 amp in 100ml Ns IV /OD
7)TAB .FEBUXOSTAT 40mg PO/OD
8) TAB BIO-D3 PO/OD

14/4/22
No new complaints
O- patient is conscious, coherent, cooperative 
Vitals
Bp-100/70 mmhg
PR-88bpm
SpO2- 98%,@ RA
Temp-97.6F
CVS - S1,S2 +
RD - BAE +
A-CKD SECONDARY TO DIABETIC NEPHROPATHY WITH ? DIABETIC PERIPHERAL NEUROPATHY WITH HTN/DM/HYPOTHYROIDISM/CKD/?CAD WITH LEFT QUADRIPARESIS SECONDARY TO CERVICAL MYELOPATHY

1) TAB.THYRONORM 25mcg PO/OD
2) TAB. OLMESARTAN-H 40mg PO
3) TAB. NODOSIS 500 mg PO/OD
4) TAB.SHELCAL 500mg PO /OD
5) INJ HAI S/C  According to sliding scale
@ 8am- 2pm-8pm
6)INJ OPTINEURON 1 amp in 100ml Ns IV /OD
7)TAB .FEBUXOSTAT 40mg PO/OD
8) TAB BIO-D3 PO/OD
9)T.Atorvastatin 10mg /po/H/S
10)IVF -NS @ UO +30ml /hr
11)TB .pregabalin75 mg /Po/H/S

15/4/22
S-neck pain radiating to back
O- patient is conscious, coherent, cooperative 
Vitals
Bp-110/70 mmhg
PR-84bpm
SpO2- 98%,@ RA
Temp-97.6F
CVS - S1,S2 +
RD - BAE +
A-CKD SECONDARY TO DIABETIC NEPHROPATHY WITH ? DIABETIC PERIPHERAL NEUROPATHY WITH HTN/DM/HYPOTHYROIDISM/CKD/?CAD WITH LEFT HEMIPARESIS SECONDARY TO CVA

1) TAB.THYRONORM 25mcg PO/OD
2) TAB. OLMESARTAN-H 40mg PO
3) TAB. NODOSIS 500 mg PO/OD
4) TAB.SHELCAL 500mg PO /OD
5) INJ HAI S/C  According to sliding scale
@ 8am- 2pm-8pm
6)INJ OPTINEURON 1 amp in 100ml Ns IV /OD
7)TAB .FEBUXOSTAT 40mg PO/OD
8) TAB BIO-D3 PO/OD
9)T.Atorvastatin 10mg /po/H/S
10)IVF -NS @ UO +30ml /hr
11)TAB .pregabalin75 mg /Po/H/S
12)TAB. Ultracet 1/2 PO/QID

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