25 year old male with diabetes with generalised weakness of both upper and lower limb

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I've 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 a diagnosis and treatment plan

A 25 year old male car driver by occupation and resident of narketpally came to opd with

Chief complaints :

-generalised weakness of both upper limbs and lower limbs since 2-3 months

History of presenting illness :

Patient was apparently asymptomatic 3 months back , then he developed generalised weakness and increase urine output 2 months back

Nocturia since more than 2 months

Then he visited local hospital and after all investigations done he got diagnosed with type 2 diabetes. He was prescribed for regular medication [ metformin ]

After using medication for 10 days , his weakness got subsided

He had 3 episodes of headache in the last 3 months which is diffuse , non radiating , on and off , throbbing type , no aggravating factors , but temporarily relieved on medication

No h/o blurring of vision , Diplopia , photophobia

H/o polydipsia

He has tingling sensation but no numbness in both upper limbs and lower limbs

H/o sob on lying down after meal and relieved on sitting position since 3 months

H/o weight loss of 4 kgs in the last 3 months

No h/o vomitings , loose stools , abdominal distension , constipation

No h/o cough , cold , fever

No h/o Orthopnea , pnd , chest pain

No h/o palpitations , sleep disturbances

No h/o hematuria

Past history :

No similar complaints in past

Not a known case of Hypertension , epilepsy , tuberculosis , asthma , tuberculosis , thyroid abnormalities

No past surgeries

Personal history :

Diet - mixed

Appetite - normal

Bowel and bladder movements - regular

Sleep - adequate

No addictions

No known allergies

Daily routine :

Diet:

Morning	2 millet roti , bowl of curry	450 calories
Afternoon	2 millet roti with dal or curry	500 calories
Night	2 millet roti with curry	450 calories
	Total	1400 calories

Required calories according to his age - 2400 calories

Calories deficit - 1000 calories

Family history :

His father is a known case of diabetes since 5 years

General examination :

Patient is conscious , coherent , cooperative

Well oriented to place , time , person

Moderately built and moderately nourished

Bilateral mid arm circumference - 12 cm

Abdominal circumference - 35 cm

Vitals -

Bp - 120 / 80 mmhg

Hr - 84 bpm

Rr - 17 cpm

Signs

Pallor - absent

Icterus - absent

Cyanosis - absent

Clubbing - absent

Generalised lymphadenopathy - absent

Bilateral pedal edema - absent

Systemic examination

Per abdomen

Inspection -

Shape of abdomen : scaphoid

Umbilicus : inverted , central

All quadrants of abdomen are moving equally with respiration

No dilated veins , scars , engorged veins , sinuses

No visible pulsations

Palpation -

All inspectors findings are confirmed

No local rise in temperature

Abdomen is soft

No tenderness

No guarding , no rigidity

Deep Palpation- no organomegaly

Percussion -

No shifting dullness

No fluid thrill

Auscultation -

Regular bowel sounds are heard

Respiratory system examination :

Inspection -

Chest appears to be bilaterally symmetrical , elliptical in shape

Trachea appears to be central [ midline ] in position

Chest in moving equal and normal with respiration

No sinus , no scars , no dilated veins , no swellings , no drooping of shoulder , no hallowing

Palpation -

All inspectory findings are confirmed

No local rise of temperature , no tenderness

Trachea -midline

Apical impulse is felt

Tactile focal fermitus - appreciated

No palpable swellings , no crowding of ribs

Percussion -

The following areas are percussed

Area	Right	Left
Supraclavicular	Resonant	Resonant
Infraclavicular	Resonant	Resonant
Mammary	Resonant	Resonant
Axillary	Resonant	Resonant
Infraaxillary	Resonant	Resonant
Suprascapular	Resonant	Resonant
Infrascapular	Resonant	Resonant