60yr old female came with the complaints of tingling and burning sensation of both lower limbs since 1year

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I have 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. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input 

A 60yr old female came with

C/o SOB since 10 days 

C/o tingling sensation and numbness of both LL since 10months 

HOPI : 

Patient was apparently asymptomatic 10months back and then developed tingling and numbness of both LL 

H/o nocturia , polyphagia present 

No h/o polyuria

C/o SOB Grade 2-3 since 10 days. No aggravating and relieving factors 

No h/o chestpain, palpitations, orthopnea,PND 

No h/o fever cough cold 

No c/o burning micturition pedal edema 

Past history

K/c/o bronchial asthma since 30yrs and on inhaler budecort

K/c/o HTN since 1month and on Losartan 50mg 

K/c/o DM type 2 since 40yra and on metformin 500mg 

Vitals: 

Temperature 98.4 f 

PR 86bpm 

BP 110/70 mm hg 

RR 18 cpm 

GRBS : 245 mg/dl 

Personal history  

Diet mixed 

Appetite decreased since 6months 

Sleep decreased d/t burning sensation of feet 

Occasionally toddy 

Alcohol consumed 20yrs back whiskey 

No Smoking

Bowel regular 

 bladder increased frequency during nite - 5 times/night decreased 

 General examination 

Patient is c/c/c well oriented to time place person 

 Moderately built nourished 

Pallor + 

No signs of icterus cyanosis clubbing lymphadenopathy generalised edema 

Vitals :

Temperature -98.2 f 

BP 120/80 mm hg 

PR 86bpm 

RR 18CPM 

GRBS : 

 

Systemic examination

CVS - S1 S2 Heard no murmurs 

RS - BAE present NVBS 

Per abdomen - Soft non tender no organomegaly

CNS - 

Higher mental functions:

Patient is conscious,coherent,cooperative,

Speech and language is normal 

CRANIAL NERVES:Intact

Olfactory nerve 

Optic nerve 

Occulomotor nerve 

Trochlear 

Trigeminal 

Abducens 

Facial 

Vestibulocochlear 

Glossopharyngeal 

Vagus 

Spinal accessory 

Hypoglossal 

Motor system:

                       Right    Left 

 Bulk      UL      n         n      

                LL       n        n

Tone       UL       n        n 

                LL       n        n 

Power     UL     5/5     5/5  

                 LL     5/5      5/5 

Reflexes: 

Superficial reflexes: present

Corneal 

Conjunctival 

Abdominal 

Plantar reflexes 

Deep reflexes:Present

                 Right      Left

Bicep        ++             ++

Triceps     ++            ++

Knee          ++           ++

Ankle        ++            ++

Co ordination present 

Gait normal 

No involuntary movements 

Sensory system: 

Pain, temperature, pressure, vibration perceived 

Romberg's test:absent

Graphaesthesia:normal 

Cerebellar signs: 

No nystagmus,Finger nose test positive,Heel knee test positive 

No signs of meningeal irritation. 

Provisional diagnosis: 

DIABETIC PERIPHERAL NEUROPATHY