A 52 year old male came to casualty with complaint of involuntary movements in right leg associated with numbness

July 03,2023.

This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent. Here we discuss our individual patients problems with an aim  to solve the patient’s clinical problem with collective current best evident based input.

This E blog also reflects my patient cantered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of  “patient clinical data analysis” to develop my competency in reading and comprehending clinical data including history, clinical  findings,investigations and come up with diagnosis and treatment plan.

 This is the case of the 52 year old male farmer by occupation resident of Lingotham.

CHIEF COMPLAINTS:

Involuntary movements in right lower limb since morning 6:00AM.

Numbness of right lower limb.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 15years ago. He was diagnosed with diabetes type 1 15 years ago.

-H/o HTN since 5years.

-He developed gangrene in his right foot toes due to trauma secondary to diabetes and undergone amputation. After amputation further infection is seen and amputation was done upto the level of metatarsals 3years ago.

-Patient complaints of rapid onset of bilateral weakness of both limbs and involuntary movements 2years ago which was relieved on medication prescribed by neurologist.

-Left leg amputation below the level of knee due to trauma induced diabetic gangrene 3months back.

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

-He noticed involuntary movements this morning at 6:00AM in his right leg rapid in onset and progressive in nature extending upto right half of trunk. He felt numbness in the right leg.

Not associated with pain and burning sensation.

No froth and tongue bite is seen.

PAST HISTORY:

N/c/k/o CAD, asthma, TB, epilepsy.

FAMILY HISTORY:

History of diabetes in the family.

PERSONAL HISTORY:

Mixed diet

Normal appetite 

Adequate sleep

Regular bowel movements

Abnormal bladder movements 

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

GENERAL EXAMINATION:

Prior consent was taken 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.

Right palpebral conjunctiva

VITALS:

Temperature- 98.6F

BP-130/80 mmhg

PR- 110bpm

RR-18cpm

Spo2-98% at room air

No associated pain

SYSTEMIC EXAMINATION:

CVS- S1S2 heard and no murmurs heard.

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

       -Normal vesicular breath sounds

P/a  -tender soft

       -no distended abdomen 

       -all quadrants moving equally with respiration 

CNS examination:

Higher mental functions are intact.

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:PA view

ECG:

EEG:

2d echo:

Arterial Doppler:

He was diagnosed with peripheral vascular disease.

PROVISIONAL DIAGNOSIS:

Focal seizures with intact sensations.

Lower motor nerve lesion secondary to diabetic neuropathy.