55yr old with uncontrolled blood sugars

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Short case

Hall ticket no. 1601006058

A 55yr old came to the OPD with the chief complaints of dizziness, abdominal pain with vomiting 2-3 times per day since 7 days

HISTORY OF PRESENTING ILLNESS:

- He had dizziness since 1 month which was aggravating on waking, not relieving, transient in duration with 4-6 episodes everyday.

- 7 days back he had a fainting spell and a fall where he lost consciousness. He is unable to stand without support since then.

- Since 7 days he is having episodes of vomiting 2-3 times per day after every meal.

GENERAL EXAMINATION:

Appearance: ill built

Breath: fruity breath

Gait: unable to stand without support.

Pulse: faint pulse, regular rhythm

CVS:

S1, S2 HEARD

Pulse rate:89/min

Apex beat at 5th intercostal area medial to the mid axillary line.

SKIN, NAIL, HANDS:

Prayer sign: positive

Lower leg shins: spots present

Foot ulcers : one ulcer on each foot.

NERVOUS SYSTEM:

On examination of the Motor System :

1. Rigidity 

2. Bradykinesia

3. Tremors

4. Gait and Coordination

1. Rigidity :

To elicit rigidity, I performed an activation maneuver by asking the patient to tap his hand on the thigh, while I simultaneously checked for rigidity in the wrist, elbow and the ankle.

No rigidity   

3. Tremors :

• Tremors are absent

• COGWHEEL RIGIDITY is not present.

• Finger-to-nose test = Normal

4. Gait and Coordination :

• Gait = high stepping gait.

                                       Right                      left

     1. Muscle bulk        poor                      poor

     2. Muscle tone         normal                normal

                                                                     

Upper limb                                                                 

Shoulder         Normal                        Normal

Elbow              normal                     normal   

Wrist           normal                   normal     

                 

Lower limb         weak                weak                     

3. Muscle Power                                                                

Upper Limb                                                                

 Proximal            4/5                               5/5

 Distal                  5/5                              5/5

Lower Limb                                                                

Proximal             3/5                               3/5

Distal                  2/5                               2/5

4. Reflexes                                                                         

 Superficial reflexes

                         Right                            Left

Corneal            +                                    + 

Conjunctival     +                                    + 

Abdominal        +                                    + 

Plantar           absent                   absent

Deep tendon reflexes

                           Right                           Left

Biceps                 2+                               2+

Triceps                2+                               2+

Supinator            2+                               2+

Knee                   --                              ---

Ankle                  --                                 --

Clonus             Absent                     Absent

On examination of the Cranial Nerves :

• Cranial Nerve 1 : The patient can perceive the smell of soap

• Cranial Nerve 2 : Can only perceive movement of hand

Field of vision decreased.

• Cranial Nerves 3, 4 and 6 : Movements of the extra-ocular muscles lost (horizontal axis)

Vertical gaze limited.

• Cranial Nerve 5 : Sensory component = Ability to perceive sensation over specific areas on the face is Normal. Motor component = Jaw jerk was elicited and the muscles of mastication are normal.

• Cranial Nerve 7 : No deviation of the angle of the mouth, no loss of nasolabial folds, he is able to puff his cheeks, grin and tightly shut his eyes.

• Cranial Nerve 8 : Rinne's test = AC > BC , Weber's test is centralized.

• Cranial Nerves 9 and 10 : Uvula is centrally placed and Gag reflex is present.

• Cranial Nerve 11 : Patient is able to shrug his shoulders against resistance. Trapezius and Sternocleidomastoid are normal.

• Cranial Nerve 12 : Patient can normally move his tongue in all directions.

On examination of the Sensory System :

Right                    Left

1. Pain                            -                          -

2. Crude touch             -                            -

3.  Fine touch               -                           -

4. Vibration sense                                         

                                   

Medial malleolus     5.7s                    4.6s

Patella                      9s                       4.3s

Elbow                      4.8s                    6.4s

Wrist                          5s                        7s

5. Proprioception    Normal             normal

6. Stereognosis        normal                  normal

7. Tactile localization       Normal        Normal

8. Two-point discrimination  lost in both legs.

GASTROINTESTINAL:

All quadrants moving equally with respiration.

No visible pulsations and scars.

Vomiting: non projectile, bilious, associated with stomach ache 

INVESTIGATIONS:

Blood test: acidosis, hyperglycemia.

Urine test: high ketones

Liver function tests:

PROVISIONAL DIAGNOSIS:

Uncontrolled diabetes mellitus with diabetic ketoacidosis