A 50 year old male with Itching
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CHIEF COMPLAINTS
50 year male farmer by occupation came with complaint of
Itching in the front and back and both upper arms since 2 months
Nausea,loss of appetite since 7days
Decreased urine output since 1day
HISTORY OF PRESENT ILLNESS
He started his career at the age of 13years(1986) as lorry cleaner who used to accompany with driver for the first 2years.At his 15years age started driving the lorry by himself.
Till 45years(2019) he continued the same profession.He used to drive 100km to and fro in a day.Depending on his requirement of money he used to work 4-6 days in a week.
5 years back as he was getting tired easily(not able to drive long distance)went to local hospital, diagnosed as having high sugars started on OHA.He stopped driving as it is more stressful and started farming his 3 acre land.
He used OHA for 1year,later switched to insulin as sugars were not in control.From 4years he is on inadequate dose of insulin.He used to take insulin dose (16U/18U) once in a day(against to twice a day dose prescribed by doctor) because whenever taking twice a day, intermittently he was having hypoglycaemic symptoms like sweating, palpitations,weakness.
2years back he had trauma(thorn prick) to left second toe, it got worsened after getting treatment for 15day by local rmp.Came to our hospital,disarticulation of left second toe was done.
From one year patient is having on and off pitting type of pedal edema till knee.No history of any associated orthopnea/PND
2months back he had itching at the back more at night.Itchy lesions gradually spread from back to front, buttocks,upper arms.
From 7days patient is having symptoms of nausea, loss of appetite.From 1day he was having decreased urine output, came to our hospital for further management.
No history any fever,orthopnea,PND,dyspnea
PAST HISTORY
k/c/o DM2 - 5years back(1year-used OHA,from 4years he was on insulin once daily)
No history of Hypertension,asthma,TB,epilepsy,thyroid disorders
PERSONAL HISTORY
He wakes up at 7:00am in the morning,go his his farm, water his field and comes back at 10:00am eats tiffin.
At 11:00am he goes back to farm and till 6:00pm he works there.Take insulin in the afternoon before eating lunch.
After coming home, he bathe and eat food at 8:00pm and sleep's by 9:00pm
He had two 2daughters.All are married and having children.
Addictions : he eats umber,drinks alcohol during occasions and family gatherings
FAMILY HISTORY
No similar complaints in the family
MEDICAL HISTORY
He takes inj insulin S/C once daily
GENERAL EXAMINATION
Patient is conscious, coherent,co-operative.Moderately built and Moderately nourished.
Blood pressure-140/80mmhg,right arm, supine position
Pulse-90/min,regular rythm,normal volume.
Respiratory rate-18/min,thoraco abdominal
Temperature-98 F
Spo2-98% on room air
Grbs-420mg/dl
No pallor, icterus,clubbing,cyanosis,lymphedenopathy,edema of legs
No raised JVP
SKIN examination :-
Papules present over back, front,upper arms, buttocks.Koebner phenomenon +.
Hyperpigmented patches diffusely present on back front and over upper arms.Right foot plantar keratosis present.
Left foot second toe is absent
SYSTEMIC EXAMINATION
CENTRAL NERVOUS SYSTEM :
Higher mental functions
-Patient is conscious, coherent,co-operative.Oriented to time, place,person.
-Speech = Fluency,comprehension,repetition intact
-Memory =Recent,Remote,Immediate : Intact
Cranial nerve examination -
2 - Visual acuity RE-6/60,LE-CF 1mts
other cranial nerves are normal
Motor examination :
Bulk of muscle normal on both sides on inspection
Hand grip 100% on both sides
Tone :
Right Left
Upper limb. Normal Normal
Lower limb. Normal Normal
Reflexes:
Right Left
Biceps. - -
Triceps. - -
Supinator. - -
Knee. - -
Ankle. - -
Plantar. flexor flexor
Sensory examination:
1.Spinothalamic: R L
Crude touch + +
Pain. + +
2.Posterior column:
Fine touch + +
Vibration Reduced
ankle -- --
Knee. -- --
Wrist. 6sec 6sec
Position sense:
LL. Rt-6/10. Lt --5/10
3.Cortic
Stereognosis: +
Graphesthesia +.
CEREBELLAR FUNCTION
Finger nose and finger finger test were norm
No dyadiadokokinesi
No pendular knee je
Heel knee test : norm
CARDIOVASCULAR SYSTEM
-Elliptical & bilaterally symmetrical che
-No visible pulsations/engorged veins on the che
-Apex beat seen in 5th intercostal space medial to mid clavicular line
-S1 S2 heard
-No murmurs
RESPIRATORY SYSTEM
Upper respiratory tract normal
Lower respiratory tract
-Trachea is central
-Movements are equal on both sid
-On percussion resonant on all are
-Bilateral air entry equal
-Normal vesicular breath sounds hea
-No added sound
-Vocal resonance equal on both sides in all are
PER ABDOMEN
-Scaphoid
-No visible pulsations/engorged veins/sinus
-Soft,non tender, no guarding and rigidity, no organomegaly
Provisional diagnosis:
Diabetic neuropathy?
Investigations:
ECG:
Final diagnosis:
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