46 year old male with spasm of upper limbs

 46 year old male from chityala came with 

c/o spasm of fingers of upper limbs with tremors since 3 days , excessive sweating , calf muscle pain and generalised weakness since 3 days . 

History of presenting illness:

Patient was apparently normal 10 years ago then he had severe stomach pain and vomitings for which he was admitted to the hospital and was diagnosed to have pancreatitis, he underwent surgery For that and was discharged.After 5 years he went to hospital with complaints of weight loss and weakness,there he was diagnosed with diabetes and was put on oral hypoglycemic drugs , his sugar levels weren’t controlled so he was shifted to insulin . (Past 6 years he is on insulin ) . 4 months ago he had an episode of seizures associated with up rolling of upballs which lasted for one minute, 5 episodes occurred in 30 minutes and in between each episode he had no memory of what had happened. He was admitted in KIMS hospital and was discharged after 5 days . He also has delusional episodes at night. Since past one week he has spasm of fingers of upper limb with tremors and has decreased pitch of voice . 

Patient has been smoking since 15 years (10 cigarettes per day ) 

Alcoholic since 15 years . 

He drinks every 2 to 3 months ( 1 week binge drinking  and stops drinking for 2 months ) he has withdrawal symptoms in between drinking episodes ( tremors) .

Daily routine: 

Before DM(Daily routine)

6 years back he used to do  JCB  business.He wakes up at 7 .Goes from nkp to kattangur, before  having bf.He usually has his bf at 10 and lunch at 2pm .He comes back at 8-9pm ,has his dinner at  and sleeps around 10 am. One day all of the sudden loss of weight for which he went to a local hospital (yashoda) and was found to have DM type 2 (540mg/dl) and was given medication( insulin).He stopped going to work since then and took rest at his home.

After DM

Patient wakes up at 4 am in the morning and collects milk from buffalos and come back to home by 7.30 and supply milk till 9.30am.Takes his breakfast at 10 am and

then takes rest.He has lunch at 1 pm and takes afternoon nap.At 4pm again he goes to buffalo farm and collects milk and supply.Comes back to home by 7.30 he will have his dinner by 9pm and goes to bed by 10pm.

Past history:

History of trauma to the Achilles tendon in 2007 underwent tendon repair surgery.

H/o pancreatitis 10 years ago , underwent surgery. 

H/o seizures 4 months ago . 

K/c/o DM since 7 years .

N/k/ c/o HTN ,CVA,CAD ,ASTHMA 

Patient is conscious, coherent and co-operative.

Mooderately built and moderately nourished.

Pallor - Absent

Icterus - Absent

Cyanosis - Absent 

Clubbing - Absent 

No lymphadenopathy

Pedal edema- Absent

Vitals : 

Temperature - afebrile 

Blood Pressure - 120/80mm hg 

Pulse Rate -   82 bpm

Respiratory Rate -  16  cpm

SYSTEMIC EXAMINATION: 

PER ABDOMINAL EXAMINATION:

INSPECTION-

Shape of abdomen : flat

Umbilicus : inverted 

All quadrants of abdomen move with respiration 

No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites 

10 cm scar is present on the abdomen ( pancreatitis surgery) 

PALPATION-

Abdomen soft

No local rise of temperature 

No tenderness

Inspectors findings are confirmed 

 No organomegaly

PERCUSSION:

Resonant note heard over all quadrants.

AUSCULTATION:

Bowel sounds heard  

CVS EXAMINATION:

INSPECTION

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse not visible

PALPATION:

Apex beat localised 

AUSCULTATION:

S1 and S2 heard

No Murmurs 

RS EXAMINATION:

INSPECTION: 

Shape of chest: bilaterally symmetrical

Expansion of chest: Equal on both sides

Position of trachea: Central

No visible scars, sinuses, pulsations

PALPATION:

Inspectory findings confirmed

No tenderness, local rise of temperature

Normal expansion of chest on both sides in all areas

Position of trachea: Central

Vocal fremitus: resonant note felt

PERCUSSION:

Resonant note heard over all areas

AUSCULTATION:

BAE positive

Vocal resonance: resonant in all areas

CNS EXAMINATION:

HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact

CRANIAL NERVES : normal 

REFLEXES

Normal, brisk reflexes elicited- biceps, triceps, knee reflex elicited and b/L ankle reflexes cannot be elicited .

Tremors - present . 

             

Investigations:

Hemogram :

Hb -14.1 %

T.c -11,400

M-46

L-44

E-01

M-09

B-0

Pcv-40.4

MCH -30.3

MCHC-34.9

RDW-CV -14.3

Plt-3.65 lakh 

Hba1c: 7.2%

FBS :140 mg/dl 

RFT 

UREA-16

Creatinine-0.7

Uric acid -2.5 

Sodium -137

Potassium -4.1 

Chloride -100

CUE :

Albumin - nil 

Sugars - ++++

Pus cells -2 -3 

Cast - nil 

LFT 

TB-1.09

DB-0.39 

SGOT - 18 

SGPT - 10 

ALP - 132 

TP - 5.9 

Alb - 3.98 

A/g - 2.07 

2d echo : 

No MR AR TR 

NO RWMA 

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTION 

NO PAH/PE 

Treatment:

Tab thiamine 100 mg po/bd 

Inj HAI s/c TID according to GRBS 

Inj NPH s/c according to GRBS