Sudden onset involuntary movement of lower limb

 3/7/23;

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Ihave 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.

A 52 year male, resident of lingotam,farmer by occupation came to the casualty with chief complaints of;

Involuntary movements of the right lower limb since morning(6:00am);

Numbness of right lower limb

History of presenting illness;

Patient was apparently asymptomatic till today morning(6:00am) when he started developing involuntary movements of the right lower limb which were sudden in onset intermittent in type and gradually progressing in nature extending upto right half of trunk.Consciousness was intact.

Associated with slight slurring of speech.

Not associated with pain.

Numbness in the right lower limb which was sudden in onset, continuous in nature.

No froathing from mouth is seen, no tongue bite is seen.

Patient had complaints of  bilateral sudden onset lower limb paraparesis 1 year back which was relieved with medication

Past history: 

History of diabetes since 15 years.( on medication since 8 years and on insulin from 2 years)

History of hypertension since 5 years

Right fore foot amputation secondary to diabetic gangrene 2 years back.

Left lower leg amputation secondary to diabetic gangrene 3 months back.

No a known case of CAD,Epilepsy,asthmaand tuberculosis.

Family history:

History of diabetes in family.

Personal history;

Diet: mixed 

Sleep - Adequate 

Appetite - normal 

Bowel movements - regular 

Bladder movements- abnormal

Addictions -No

Family history- 

No significant family history

General examination -

Patient was conscious, coherent and co-operative.

No pallor

No icterus, cyanosis, clubbing, lymphadenopathy, edema.

VITALS

Temperature - 98.8F

BP- 130/80mmhg

PR -112 bpm

RR-20 cpm

Spo2 99%  room air 

Grbs- 157

Investigations: 

Chest.xray 

Ecg:

EEG: 

2d echo:

Arterial Doppler:

He was diagnosed to have peripheral vascular disease 

Systemic examination:

Cvs - S1 S2 present 

R/s - bilateral air entry present 

P/a:tender soft

CNS examination:

Reflexes -

                           Right            left

Bicep:                   +1.                +1

   

Tricep:                  +1                  +1

Supinator:           +1.                  +1

Knee:                    +1.                  +1

Ankle:              Not elicited.  Not elicited.

Provisional diagnosis:

Focal seizures with intact awareness.

Peripheral artery disease of left foot with below knee amputation(23/3/23) and right forefoot amputation.

Treatment history :

Insulin(isophane) injection -

Human mixtard 30/70

30units morning - and 30u in the night.

T.amlong 5mg po/0d at 8am.