A 52 year old patient came to casualty with c/o shivering in right leg since 10 am with associated numbness

 July 3rd,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.

HOPI:

-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 metformin 500 mg tablets.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 ( isophane) 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 four years.

H/o of HTN since 5 years

Been using amlodipine since diagnosed as HTN patient.

K/c/o peripheral artery disease

N/k/c/o Asthma,,thyroid disorder.

Personal history:

Diet: mixed 

Sleep - Adequate 

Appetite - normal 

Bowel movements - regular 

Bladder movements- abnormal

Addictions -No

Family history- 

No significant family history

General examination -

Patient was conscious, coherent and co-operative.

No pallor

No icterus, cyanosis, clubbing, lymphadenopathy, edema.

VITALS

Temperature - 98.8F

BP- 130/80mmhg

PR -112 bpm

RR-20 cpm

Spo2 99%  room air 

Grbs- 157

Investigations:

Ecg:

Chest x ray:

EEG:

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.