42 year old male with decreased strength in B/L lower limbs
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Hemogram
LFT:
FBS:
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 is welcome
A 42 year old gentleman from a South Indian town, an ex driver presently a porter in a rice mill who was apparently healthy 2 months back suddenly developed weakness in both his lower limbs which was evident with the patient being unable to wake up from his bed in a hospital in which his daughter was admitted for a certain medical condition and walk normally to the restroom, with the man finally falling onto the ground due to the same. Following the incident he used to walk taking support of the walls and also found it progressively difficult to do small tasks involving his upper limbs like eating food and buttoning/unbuttoning his shirt. He perceived a tingling sensation during these events that progressed initially from the lower limbs to the upper limbs. He refused admission for the same and was prescribed medication by the doctors there of which no records exist with the patient. After a period of time with no resolution of his complaints he visited a doctor in another town who advised routine blood investigations and subsequently was found to have then a serum K+ level of 3.2mEq/L. That doctor upon examination noted the man being unable to dorsiflex both his feet against resistance with left being considerably weaker than the right.
The same doctor advised for a neurologists' opinion and prescribed the following drugs which the patient took for 20 days
1.Tab.PREGAB NT
2.Tab.NEUROBION FORTE
3.Tab.RAZO D
4.Tab.SHELCAL
He also gives a history of consumption of some unknown medication in red colored vials bought from a pharmacy which he consumed every alternate day for 10 days.He noticed mild improvements with the doctors drugs but subjectively felt better after taking the unknown medication.with him being able to walk better.He also gives history of taking drugs prescribed by a local rural unqualified healthcare practitioner. He then came to the hospital for further evaluation of his condition.
No H/O of fever, SOB palpitations, chest pain, decreased urine output, deviation of mouth, slurring of speech, nausea, vomiting and diarrhea.
He gives no past history of the same events occurring before in his life and also the same not being seen in other members of his family.
He's not a known case of DM,HTN,Asthma,TB
He has no history of suffering from CVS disorders and Thyroid disorders
He has no history of past surgeries
He has no known allergies to drugs
He has no known food allergies
His Appetite has decreased since his admission in the hospital, with his diet remaining unchanged
No sleep disturbances
His bowel and bladder movements are normal with him complaining of passing mild quantities of frank blood in stools(He's straining for the same)since 3 days after admission.
Addictions - he's an occasional alcoholic since 22 yrs and usually consumes around half a bottle of locally made whiskey with his peers.
Upon general examination the patient was conscious, coherent and oriented to time, place and person.
He had no signs of Pallor, Icterus , cyanosis, clubbing, lymphadenopathy and was Afebrile
His PR- 84bpm ;B.P.- 110/70mmhg ; R.R- 17cpm
CVS- S1,S2 heard with no murmurs
Resp- B/L AE(+),no wheeze or crepts
GIT- P/A soft, non tender, no organomegaly or distended veins noted
CNS - MMSE - normal
speech is normal
All cranial nerves are normal
Motor system -
Power - upper limb- normal
lower limb- left ankle dorsiflexion is 4-/5
no wasting of muscles noted
no loss of coordination
no involuntary movements noted
Reflexes- B/L ankle jerks were absent
Sensory system-
Spinothalamic tract- pain- nil
temp- can perceive temp changes
Dorsal column tract- fine touch- N
vibration- 6 seconds in both L/L
proprioception- N
cortical sensations - N on both sides
Cerebellar functions are normal
The following investigations were ordered:
ECG
Hemogram
CUE:
HbA1c:
chest xray
He was put on the following drugs on admission:
1.Inj OPTINEURON 1amp in 100ml NS/IV/OD
2.Tab.BENFOMATE PLUS/PO/OD(×-1-×)
3.Tab.PREGABALIN- NT PO/OD/H/S(×-×-1)
4.Physiotherapy of both the lower limbs
Problem representation: A 42 yr old previously healthy man, working in a rice godown, presented with a 2 month history of slowly progressive bilaterally symmetric sensorimotor polyneuropathy.Labs revealed a HbA1c of 6.5 and he was diagnosed with type 2 Diabetes with Diabetic neuropathy.The lower GI bleeds were attributed to anal hemorrhoids.
Course in hospital: complained of 1 episode of bleeding per rectum with minute quantity of frank blood with hard stools 3 days after admission and was advised Syrup CREMAFFIN H/S , high Fibre diet, plenty of oral fluids and Sitz bath with betadine TID.
The patient subjectively feels better with decreased perception of tingling sensation and improved strength in lower limbs but objectively was found to have no improvement in power.
Was discharged after 5 days of admission and was asked to visit the OP clinic with reports of NCTs' advised to him on discharge.
He was prescribed a multivitamin and advised to continue taking cremaffin syrup till resolution of GI symptoms.
