60/M with Peripheral Neuropathy Secondary to DM2

 02-09-2023

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Khushi Tulsyan, Intern

Roll no. 49

Pt was admitted in Ward 10 on 01/09/2023

Patient came with complaints of 

-Left shoulder pain since 1.5 month. 

-Complains of numbness and tingling of bilateral foot since two years.

HISTORY OF PRESENTING ILLNESS-

Patient was apparently a symptomatic 2 years ago. Then he developed numbness, tingling sensation of bilateral foot with loss of sensation on wearing slippers which is associated with burning sensation of b/l foot. Patient also complains left shoulder pain with restricted movements since 1.5 month.

Ortho referral was done i/v/o Frozen shoulder and was advised Physiotherapy and medications (Tab Hifenac , Tab pan 40 mg , Systaflam gel)

Opthal referral was done i/v/o DR and was found to have Grade 2 NDR changes and was advised Nepfenac drops 

PAST HISTORY-

History of seizures one episode 40 years back. He is a known case of DM 2since 14 years and is on Tab GlimiM2POBD 

He is not a known case of hypertension, CAD ,CVA , TB and asthma 

FAMILY HISTORY-

Not significant

PERSONAL HISTORY-

Daily Routine-

He wakes around 6 AM and get ready to go to work and works for around 5-6 hours and comes back home have rest, he has his regular meals at 8AM ,1 PM and 8 PM and retires for the day around 10PM.

Diet - Mixed

Appetite - Normal

Bowel and bladder movements- Regular

Addictions - Alcohol occasionally.

GENERAL EXAMINATION-

Consent was taken.

Patient was examined in a well lit room with adequate ventilation with a attendant present.

Patient is conscious coherent and cooperative well oriented to time place and person moderate built and nourished.

Pallor mild present

No signs of icterus clubbing cyanosis lymphadenopathy edema

Temp - 98 F

BP -120/ 70 mmhg

PR- 78 bpm

GRBS - 316 mg/dl

Spo2 - 97% RA

CVS - S1S2 +  No murmurs

RS - NVBS BAE +

CNS - 

Cranial Nerves Examination- Normal

Reflexes - 

B ++     ++

T ++   ++

S ++     ++

K++     ++

A+      +

Motor -

Power - 

U/L - 5/5   5/5

L/L -  5/5   5/5

Tone -

U/L - N    N

L/L -  N   N

Sensory - 

P/A - Soft and Non Tender

Provisional Diagnosis-

Diabetic Nephropathy secondary to DM2

INVESTIGATONS -

RBS - 316 mg/dl

FBS - 332 mg/dl

Hb - 10.4 gm/dl

Tlc - 9700

Plt - 2.92 lakhs

Urea - 56

Creat - 1.2

ECG - Sinus Rhythm

USG of Left shoulder - Normal

X Ray Shoulder -

Treatment-

Tab Glimi M2 PO/BD 

Tab Pregaba 75 mg PO/HS

Nepfenac drops

Tab Hifenac

Tab Pan 40 mg

Systaflam Gel

Glycemic control and diabetic diet

Physiotherapy

Pt was discharged on 02/09/2023 with above medications and was asked to come back  review to GM OP with FBS and PLBS report after a week and Ortho OP on 09/09/2023