case presentation

1. Staff Round
Prof. Dr. Aassem Seif
Presented By :
Riham Hamdy Mostafa
Neurology Resident

2. Personal History :
OM.F.E male patient, 34 years old ,born and living
in Haram, married for 9 years with no offspring.
tailor, with no special habits of medical importance
and he is right handed.

3. Complaint:
Obilateral lower limb weakness of 2
weeks duration.

4. Present History :
O The patient is known to have DM since the age of
14 and is on insulin long and short acting but is not
compliant.
O The condition started 5 months ago with left loin
pain which was dull aching, moderate to severe in
intensity, radiating to groin and partially relieved
after water intake. The condition was also
associated with fever, that reached up to 40 © ,
with no diurnal variation and responded to
NSAIDS. There is history of precipitancy but no
hematuria or renal stones.

5. O The patient sought medical advice, where
investigations were done and revealed UTI and
neurogenic bladder. He was prescribed Antibiotics,
NSAIDS and pyridostigmine. He overused the
NSAIDS.
O His symptoms were temporarily relieved and
returned again after stoppage of medications.
Present History :

6. O2 weeks ago, UTI and fever recurred again and
the condition was associated with dyspnea on
exertion, orthopnea, LL edema followed by
abdominal distention, epigastric pain, nausea and
vomiting of food particles not related to meals.
O There is history of occasional diarrhea, but no
history of jaundice or bleeding from any body
orifices. No history of PND, chest pain or
palpitations. No history of cough, hemoptysis or
expectoration.
Present History :

7. OOne week later ,the patient experienced
bilateral LL weakness , acute in onset, more on the
left side, distal more than proximal, not associated
with abnormal movements or wasting.
O The condition was associated with diminished
sensation in both LL ,also numbness and tingling
sensation till both knees , but no symptoms
suggesting deep sensory loss.
Present History :

8. Present history:
OThree days , later the patient started to have stool
and urine incontinence and loss of morning
erection. There’s history of retrograde ejaculation
diagnosed 5months ago but no history of symptoms
suggestive of cranial nerves or speech affection. No
history of trauma. The pt was transferred to our ER
O No history of other system affection.
O Patient is not known hypertensive.

9. Past History :
O H/O hospital admission at age of 14 due to
DKA.
O H/O of argon laser ablation for his retina
(diabetic retinopathy )
O No history of blood transfusion or operations.
O No h/o food or drug allergy
O No history of TB or B

10. Family History :
O His mother and father are of second
degree relatives
O His father was diabetic
O No similar conditions in his family

11. SUMMARY
O 34 yrs old male with T1DM
O 5 months ago: recurrent UTI and fever
O 1 month ago: UTI, fever, dyspnea on
exertion, LL edema and abd distention,
epigastric pain, vomiting
O 2 weeks ago: acute onset of weakness
and sensory loss in both LL, urine and
stool incontinence, loss of morning
erection.

12. General Examination :
O The patient is fully conscious well oriented to time
and place and persons, with average mood and
mentality , intact memory, average built ,lying
comfortably in bed.
O Vital signs :
 BP: 110/70 ,postural hypotension cant be assessed
 HR: 84 BPM regular, big pulse volume ,equal on
both sides , no special character, vessel wall not felt
with intact peripheral pulsations.
 RR: 16 breath/ min
 Temp: 37 © once 38.5 ©

13. O Head and neck examination:
O Pallor
O Inflammed gums and tongue
O Lost teeth
O No jaundice or cyanosis
O Trachea is central and carotid pulse equally felt on
both sides
O No congested neck veins or palpable lymph nodes
General Examination :

14. O Extremities :
UL:
O 1st degree clubbing
O No tremors
O No palmer erythema
LL:
O Diabetic dermopathy
O Intact peripheral pulsations
O Lax calf muscles
O loss of hair
General Examination :

15. O Cardiac examination :
OApex in the 5th Lt intercostal space MCL
ONo evidence of chamber enlargement
ONormal S1& S2.
ONo additional sounds or murmurs
O Chest examination:
ONormal vesicular breathing
OEqual breath sounds on both sides
ONo additional sounds
Examination:

16. O Abdominal examination:
O Inspection:
Epigastric pulsations, abdomen is mildly distended
but moves freely with respiration, divarication of
recti, umbilicus is shifted down, normal in shape with
no pigmentation, scar, discharge or impulse on
cough. Normal skin, no visible or dilated veins,
normal hair distribution, normal genitalia and back
examination.
Examination :

17. O Palpation:
* Superficial Palpation: no tenderness, rigidity or
palpable masses
* Deep Palpation:
liver: Upper border of the liver is in the 5th space rt
MCL
No other organomegaly by deep palpation
Renal angle not tender
O Percussion : by light percussion liver is felt 2 finger
below costal margin
no ascites detected by shifting dullness
O Auscultation: Normal audible intestinal sounds
No renal artery bruit
Examination :

18. Examination :
O Neurological examination:
O Speech : normal
O Cranial nerves: pupils RRR but delayed reaction bil,
O Motor :
O Inspection:
No wasting or hypertrophy ,no fasciculation
No involuntary movement or skeletal deformities
O Tone :
Hypotonia in LL

19. O Power;
OUpper limb : normal
OLower limb : Weakness ( see table)
Extensors more than flexors
Proximal =distal
O Reflexes:
Deep: areflexia in LL ,
Pathological: -ve ,
Superficial: equivocal , preserved abdominal
reflexes
Examination :
Neurological examination:
Motor :
side right left
upper 5 5
lower 3 , 4+ 2, 4

20. O Neurological examination:
O Sensory:
Upper limb : normal
Lower limb :
Superficial sensation: gloves and stocks hypothesia
below knees
Deep sensation :vibration sensation affected till
patella
Sense of position and joint movement
affected
Romberg sign cant be assessed
Examination :
Sensory level
till T 12
Gloves and
stocks

21. O Neurological examination:
O Coordiantion : normal
O Gait : cant be assessed
ambulant with bilateral support
O Back and spine : normal
O Cranium and neck : normal
Examination :

22. Investigations:
O Laboratory:
TLC 19 ALT 21 CA 8.2
HB 6.4 AST 25 MG 1.4
MCV 73 UREA 14 NA 131
MCH 25 CREAT 3.36 K 5.8
PLT 633 URIC
ACID
9.1 CRP 95.1
PC 65 BIL T/D 0.4/0.1 ESR 1ST 122
PT 16 ALP 178 MICROA
LB
1563
INR 1.32 ALB 2.8 HBa1c 11.4
IRON 23 T PTN 6.8
TIBC 201 RETICS 1.20
T.SAT 7.6% ACETON
E
NIL

23. Investigations:
O Laboratory:
18/7 18/7 19/7 20/7
ph 7.24 7.26 7.35 7.24
pco2 29 30 26 30
po2 37 47 87 41
hco3 12 13.5 14 12.9

24. O Laboratory:
Investigations :
3/5 1/7 9/7 15/7
Pus cells 60-70 Over 100 70-80 20-25
albumin + + nil +
glucose + ++ +++ ++
creat 3.0 3.46
c/s E coli E coli

25. O Imaging:
O Ecg : normal sinus rhythm
O Urodynamic studies 16/3/2017:
Investigations:

26. O Imaging:
O Abdominal ultrasound 19/7/2017:
O Right kidney 127x61 mm
O Left kidney 119x60
O Bilateral grade two to three nephropathy
O Mild ascites
O Biliary mud
O hepatomegaly
Investigations:

27. O Imaging:
O Nerve conduction velocities 22/7/2017:
Severe sensory motor axonal polyneuropathy in both
upper and lower limb
Investigations:

28. O Imaging:
O MRI spine 22/7/2017:
Investigations:

29. Problem list:
PARAPLEGIA
DM
CKD

30. Differential diagnosis :
O Transverse myelitis
O Diabetic peripheral neuropathy (autonomic )
O Guillian barre syndrome

31. Neurological Complication Of
Diabetes Mellitus
CNS
METABOLIC
CVS
PNS
FOCAL
GENERALIZED

32. Diabetic Peripheral Neuropathies
• DSP
• autonomic
neuropathy
chronic
• diabetic
amyotrophy
• Insulin neuritis
acute

35. Diabetic Peripheral Neuropathies

36. Diabetic Autonomic PNS :