52 year old male patient presented to casualty with C/o shivering in right leg associated with numbness since 1 day
52 year old patient came to casualty with c/o shivering in right leg associated with numbness since morning of July 3
July 4, 2023
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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.
Chief complaints
52 year old Patient came to casuality with complaints of involuntary movements in the right leg since 10 am morning with associated numbness.
History of Present Illness
Patient was apparently asymptomatic 15years back then he developed fever,sudden in onset.Then he visited hospital and was diagnosed with type 2 diabetes and was prescribed medication. 4 years back he had a thorn prick on the right foot and it didn't heal in time and slowly gangrene developed and 2,3,4 th right toes are amputated. Later after 1 year the gangrene progressed to great toe and little toe and they were amputated.As his sugar levels were not under control during that time he was given insulin replacing former metformin tablets. He was also diagnosed with hypertension and given amlodipine.4 months back he had a injury while driving a bike. Infected abscess was developed. 1 month later ulcer developed and below knee amputation was done.
2 years back he had numbness in both lower limbs and he consulted a neurologist where he was given medication(medication unknown). He used them for 6 months later discontinued after improvement in the condition.
On 3 July morning 6 o'clock he developed involuntary movements in the right lower limb, sudden in onset, gradually progressive Involuntary movements initially started in the calf muscles and later progressed to hamstrings and upto shoulder .There is slurring of speech. Involuntary movements are aggrevated on flexion of the limb. Tingling sensation and numbness in the right upper and lower limb and right side of the chest. Involuntary movements are not seen for 1 hour and later again he started having movements.
Past history
H/o DM since 15 years
Been on metformin tablets for first eleven years after diagnosed, then shifted to insulin(isophane)injections for the last 4 years
H/o of HTN since 5 years
Been using amlodipine since diagnosed as HTN patient
K/c/o peripheral artery disease
Not a k/c/o Asthma, thyroid disorder
Personal history
Diet - mixed
Sleep - Adequate
Appetite - normal
Bowel movements - regular
Bladder movements- abnormal
Addictions - Nil
Family history
No significant family history
General examination
Patient was conscious, coherent and co-operative.
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No edema
VITALS
Temperature - 98.8F
BP- 130/80mmhg
PR -112 bpm
RR-20 cpm
SpO2 99%
Investigations
ECG
Chest x ray
2D Echo
Arterial Doppler
He was diagnosed to have peripheral vascular disease
Systemic examination
Cvs - S1 S2 present
R/s - bilateral air entry present
P/a:tender soft
CNS examination:
Reflexes -
Right left
Bicep: +1 +1
Tricep: +1 +1
Supinator: +1 +1
Knee: +1 +1
Ankle: Not elicited Not elicited
Provisional diagnosis
Focal seizures with intact awareness.
Peripheral artery disease of left foot with below knee amputation(23/3/23) and right forefoot amputation
Treatment history
Insulin(isophane) injection -
Human mixtard 30/70
30units morning - and 30u in the night
T.amlong 5mg po/0d at 8am
