Posted by Gamal Hassanein Monday, March 2, 2015
A known diabetic patient male patient, 46 years old, from ……….…., ………..……, married and has 3 off spring, the youngest is 16 years old, heavy smoker with no other special habits of medical importance, he is Rt. handed.
c/o
Loss of sensation in both hands and feet of 15 years duration.
HPI
The condition started 15 years ago by nocturnal burning painassociated with tingling, numbness started in both feet then progressed, one year later , to involve both hands then the patient developed gradual loss of sensation in both hands and feet, and he felt as if he walkedon cotton.
4 years later, the patient experienced weakness associated with flaccidity, falling of hair, brittle nails with no wasting or twitches. This weakness started in L.Ls then progressed, one year later, to involve both ULs. It's more in distal than proximal muscles, in extensor more than flexor muscles, in adductor more than abductor muscles. The patient also suffers from unsteadiness during eye closure with no involuntary movements.
The condition was associated with diminutionof vision, visual field defects, disturbance of color vision, ptosis in both eyes for which the patient was investigated and treated by laser photocoagulation more than once. The patient can't close his eyes firmly, with accumulation of the food behind both cheeks, no symptoms of other cranial nerve affection.
The patient has organic impotence with lost morning erection with no history of drugs known to cause erectile dysfunction.
The patient developed unsteadiness during standing with palpitation, nocturnal diarrhea, gustatory sweating and dyspepsia.
No symptoms of increased I.C.T.
No speech disturbance.
No symptoms suggesting other system affection.
Past history
- There is past history of D.M started 20 years ago manifested by polyuria, polydypsia, polyphagia. The patient is on insulin treatment and his blood sugar is out of control.
- There is past history of HPN started 15 years ago manifested by headache, blurred vision. The patient is on capoten and his hypertension is not controlled.
- Appendectomy operation was done at the age of 20 years.
- No history of other drug intake.
Family history
- No similar condition in family.
- No consanguinity.
- No common disease in family.
General exam
- Temperature: 37.2o c.
- Bl. Pressure: 140/80 (Recumbent position), 100/60 (standing position).
- Pulse: regular, 110 beat/minute, average volume, no special character, vessel wall not felt, equal in both sides with absent dorsalis pedis, anterior and posterior tibial and popliteal pulsation with intact femoral, radial, brachial and axillary pulsation.
- Mentality: The patient is fully conscious, well oriented for time, place and person. Average mood and memory. The patient is co-operative with average intelligence.
- Head: Examine for Retinopathy, teeth (Artificial teeth).
- L.L: Trophic ulcer, diabetic dermopathy.
Sensory:
- Superficial sensations: above knee and elbow level stock and glove anesthesia. Circumferential comparison must be done to exclude diabetic radiculopathy.
- Deep sensation:
§ Joint sense lost on both sides.
§ Vibration sense lost at level of peripheral nerve (medial malleolus, radial styloid process) with intact vibration sense at the level of posterior column (ASIS, clavicle).
§ Muscle sense lost (Calf muscles).
§ Lost nerve sense (Ulnar and lateral popliteal nerves).
§ +Ve Romberg's test.
- Cortical sensation : can't be examined due to loss of superficial sensation.
Examination of Speech:
Normal.
Examination of Cranial Nerves:
- Optic Nerve is affected in the form of: diminution of visual acuity (Rt. eye : can count fingers at one meter, Lt. eye :blind), Tubular visual field defect .
- Ocular nerves
§ Inspection: bilateral ptosis (thumb test >> can't elevate his eye lids),pupils are dilated and irreactive to light or accommodation with no squint.
§ Power: loss of eyeball movements in all direction denoting paralysis of recti and oblique muscles of the eye.
N.B: nystagmus and conjugate eye movements can't be examined b because of loss of eye movements on examining each eye separately .
§ Reflexes: absent light and accommodation reflexes.
- Facial nerve
§ Inspection: symmetrical forehead, obliterated nasolabial folds on both sides with no tearing, no drippling of salive, no mouth deviation
§ Power: patient can't close his eyes firmly, can't elevate his eye brows , can't whistle, can't show his teeth, can't blow his cheeks
§ Reflexes: absent glabellar reflex à (bilateral LMNL).
Examination of Motor System :
Inspection__
- There is wrist and ankle drop, trophic ulcer in L.L, loss of hair and brittle nail in U.L,L.L.
- No muscle wasting, no skeletal deformities, no involuntary movement.
Examination of Tone__
- Bilateral symmetrical hypotonia in both upper and lower limbs.
Percussion__
No fasciculation or myotonia.
Examination of Muscle Power
- Bilateral symmetrical Weakness in both upper and lower limbs. It is distal more than proximal, abductors more than abductors, extensors more than flexors.
- Abdominal muscles: weakness may be attributed to trunkal neuropathy or related to myopathy as the patient gives history of thyrotoxicosis.
Coordination
Coordination cannot be examined on both upper and lower limbs because of weakness.
Reflexes
- Deep reflexes: Areflexia in both upper and lower limbs.
- Superficial reflexes: lost plantar reflex in both L.L., lost abdominal reflex (trunkal neuropathy).
N.B: lost planter reflex may be due to loss on sensation on the sole of the foot, LMNL at S1, weakness in muscles of the big toe or skeletal deformities in big toe).
Back: No deformity, no swelling, no scars .
Gait: stamping (may be high steppage).
other system examination (search for autonomic neuropathy):
Cardiovascular system:
- Absent respiratory sinus arrhythmias.
- Persistent sinus tachycardia (already examined with pulse, and ask for palpitation).
- Painless myocardial infarction.
- Postural hypotension (already examined with pulse).
Genitourinary:
- Bladder disturbances (incontinence à ask for it)
- Impotence (psychic and organic à ask for it)
Marked sweating specially with meals (gustatory sweating à ask for it )
Gastrointestinal:
- Gastroparesis diabeticorum (ask for dyspepsia).
- Diabetic enteropathy (ask for nocturnal watery diarrhea and constipation).
pathogenesis
Sorbitol pathway.
Investigation
- For diabetes: Bl. Sugar level with HBA1C, ECG, RFTs, blood lipid profile (cholesterol, HDL, LDL, TG)
- For P.N: Nerve Conduction velocity.
Treatment
- For diabetes: tight control.
- For the P.N.: Tegretol, gabapentin, vitamins, aldose reductase inhibitor
(disappointing results).
Diagnosis :
Diabetic Peripheral Neuropathy
N.B.
Lost abdominal reflex in this case may be due to trunkal neuropathy.
Abdominal muscles power can't be examined by resistance because of proximal myopathy à the patient has history of Thyrotoxicosis.
Lost knee reflex à not related to high stock level as lost superficial sensation has nothing to do with deep reflexes but is related to lost deep sensation at the level of the knee (evidenced by lost vibration sense at the knee and may be due to amyotrophy due to femoral neuropathy).
No muscle wasting à mainly sensory.
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