Biodata

Name: Kate Kamyongonya

Age: 65 Years
Sex:Female
Address: Bushenyi
Religion: Protestant
Tribe: Munyankole
Date of Admission:1st May 2010
Presenting Complaint
Headache
Dizziness 5/7
Numbness
History of Presenting Complaint
This is a known diabetic and hypertensive patient for the last 10 years who was stable on her medications until 2
days ago when she started feeling headache. The headache was throbbing in nature and very severe. It was felt in
the back of the headache. The headache is not relieved by paracetamol and is associated with dizziness. She
described the dizziness as if the earth is rotating around her. She denied any history of diplopia, syncope or
paralysis.
On further inquiry she also said that the dizziness is associated with vomiting. The vomiting is projectile in nature
and it contains what she has just eaten. However the is no history of diarrhea, or abdominal pain.There is no
history of tarry stool or yellowing of the eyes.
The numbness started 2 weeks ago and it involves the left side of her body. The numbness is associated with
tingling sensation and sometimes painful episodes especially in the abdomen.This numbness is more pronounced
in the lower extremities.
Review of Systems
Respiratory
There was no cough, fever or night sweats.
Cardiovascular System
There is no history of syncope, palpitations , chest pain, intermittent claudication or leg swelling.
Musculoskeletal
There is no joint pain or swelling or movement limitations.
Past medical History
She is a known diabetic patient who was on metformin and glibenclamide . She is also a known hypertensive
patient on medications. However she does not remember the name of drugs. Her serostatus is negative. There is
no history of other chronic illnesses in the past
Past surgical Hisotry
He had never been operated before. She did not have any blood transfusion or road traffic accidents.
Family Hisotry
She is the fifth born in a family of seven. Her parents died of old age.Her brothers and sisters died of diseases she
does not know. One of her daughters has diabetes and on treatment. There is no history of sickle cell disease or any
other familial illnesses apart from diabetes.
Social History
She stays at her daughter’s house She is has never gone to school. She has never drunk alcohol or smoked cigarette.
Summary
This is a 65 year old known diabetic and hypertensive patient who presented with a 2 day history of headache in
the occiput, vomiting and feeling of spinning of the earth around her and numbness associated with tingling
sensation.
Physical Examination
General
Sick looking overweight old woman lying supine with no respiratory distress . She has no jaundice ,pallor,
cyanosis, or finger clubbing. There was no edema , lymphadenopathy or signs of dehydration.
The vital signs were as follows
Pulse: 60/min
Respiratory rate : 24/min
Temperature: 36.9 oC in the axilla.
Respiratory System
There are no signs of respiratory distress , chest deformities, scars or local swellings.The trachea was centrally
placed. The chest expansion was symmetrical. The vocal fremitus was normal and the percussion note was
resonant bilaterally. The chest was clear to auscultation bilaterally
Cardiovascular system
The blood pressure was 120/80 mm Hg. The pulse was of normal fullness and regular.The jugular venous
pressure was not raised. There were no chest markings. The point of maximal impulse was visible at the fifth
intercostals space midclavicular line. There were no palpable thrills or heaves. The heart sounds S1 and S2 were
heard and there were no murmurs or any other added sounds.
Abdomen
The abdomen was not distended. It was moving with respirations. There were no surgical or therapeutic
scars.There were no visible collaterals or signs of liver disease such as spider angiomata.
On light palpation there was moderate tenderness in the suprapubic region. However there was no rebound
tenderness or guarding. On deep palpation the liver and spleen were not palpable and there were no other masses
palpable. On auscultation bowel sounds were present and of normal frequency.
Central Nervous System
Conscious, alert and oriented. There were no signs of meningeal irritation.
Cranial nerves:The cranial nerve examination was significant of reduced visual acuity on the right eye. The visual
fields were normal. There was reduced pinprick and light touch sensation on the right side of the face in the
distribution of trigerminal nerve. The rest of cranial nerves were grossly intact.
Upper limb: Pinprick , light touch and temperature sensation were reduced in the right arm in all dermatomes.
There is hypertonia in the right arm. There was 1+ deep tendon reflexes in the upper limbs. The power, and
coordination were intact
Lower limbs: Sensory modalitites were reduced in the right lowerlimb. Position was impaired in the right leg.
There is hypertonia in the right leg with 2+ deep tendon reflexes on both legs. Babinski response was plantar
flexion.Romberg test was negative. The power and coordination were intact.
Gait: The gait was normal
Impression
Diabetic neuropathy
Differential Diagnosis
Vitamin B12 deficiency
Chronic inflammatory demyelinating polyradiculoneuropathy
Investigations
Random Blood sugar: 366 mg/dl
HB A1c : not done.
Treatment
Vitamin B complex
Glibenclamide 5 mg bd
Metform 1g bd
Carbamazepine 100 mg bd
Captopril 25 mg bd
Nifedipine 20 mg bd
Follow UP
3rd May 2010
The random blood glucose level was 275 mg /dl.The plan was to continue the medications. Her vital signs were
Respiratory rate: 24/min
Pulse rate: 77/min
Temperature: 35.50C
Blood pressure: 170/100
4th May 2010
The patient was stable. The random blood glucose level was 400 mg /dl. The plan was to continue medications.
Her vital signs were
Respiratory rate: 23/min
Pulse rate: 74/min
Temperature: 35.70C
Blood pressure: 173/100
10th May 2010
The patient was discharged on oral hypoglycemics.
Discussion
Involvement of the peripheral and autonomic nervous systems is probably the most common complication of
diabetes. Clinical diabetic neuropathy is categorized into distinct syndromes according to the neurologic
distribution, although many overlap syndromes occur. In both type 1 and type 2 diabetes, the prevalence varies
with both the severity and duration of hyperglycemia.
My patient had diabetic neuropathy , especially sensory ,as evidenced by the symptoms she presented with.She
presented with paresthesias which affected her left side of her body. The laboratory investigations that should be
done are those to exclude other causes of neuropathies such as vitamin B12, complete metabolic panel , complete
blood count and erythrocyte sedimentation rate.
Of all the treatments, tight and stable glycemic control is the most important for slowing the progression of
neuropathy.
Many medications are available for the treatment of diabetic neuropathic pain. These include tricyclic
antidepressants, gabapentin, pregabalin, duloxetine, topical lidocaine, and capsaicin. Other medications such as
carbamazepine, oxcarbazepine, phenytoin, lamotrigine, and opioids may also be used.
References
1. -Fauci et al Harrison’s Principles of Internal Medicine 17th Ed. McGraw Hill Inc. 2008.
2. http://emedicine.medscape.com/article/1170337-treatment