57 year old patient with diabetic neuropathy

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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.

57 year old Patient came to the OPD with

CHEIF COMPLAINTS:

Tingling sensations of all four limbs since 1 year.

HOPI:

Patient was apparently asymptomatic 1 year back then he developed tingling sensations of lower limbs which progressed to upper limbs ( frequency: lower limbs >upper limbs)

No c/o burning sensations, paresthesias.

No c/o polyuria, polyphagia, polydypsia.

PAST HISTORY:

K/c/o Type 2 Diabetes mellitus since 10 years

Not a K/c/o HTN,CAD,CVD,Thyroid disorders, Epilepsy 

Patient was using medication for diabetiesi.e, Tab.Metformin 1000mg

Tab.Glimiperide 2mg

Tab.Voglibose 0.2mg 

Personal history -

Diet - Mixed 

Sleep - Adequate 

Appetite - normal 

B&B - regular 

Addictions:Alcohol -Occasionally

 

Family history- 

No significant family history

General examination -

Patient was conscious coherent co-operative

 

Pallor - absent 

No icterus, cyanosis, clubbing, lymphadenopathy, edema.

VITALS

BP- 110/80mmhg

PR -84bpm

RR-18cpm

Spo2 99% at room air 

Temperature -98F

SYSTEM EXAMINATION 

Cardiovascular System:   

INSPECTION:-

Chest appears normal in shape

Apex beat is not visible

PALPITATION:

Apex Beat - diffuse No palpable murmurs (thrills)

ASCULTATION:-

S 1; S 2 heard

Central nervous system: No focal neurological deficits.

Respiratory system: 

INSPECTION:

 Shape of Chest - normal

 Trachea position central

 Movements of the chest: Respiratory rate- 18cpm.

PALPITATION:

 No local rise in Temperature and tenderness

 Expansion of the chest- equal in all planes 

PERCUSSION:

Resonant all over the chest except infraxillary area left side

AUSCULTATION:

Normal breath sounds were heard in all areas except the left infra axillary where there are decreased breath sounds.

INVESTIGATIONS:

ECG:

USG: