Case of 72 year old female with tingling and numbness in bith lower limbs

 This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.


A 62 old female who is a resident of voligonda , house wife by occupation came  with the 


 Chief complaints 


Tingling and burning sensation in both the lower limbs since 2 months 


Swelling of both the lower limbs since 2 months  


History of presenting illness

The patient was apparently asymptomatic 2 months.

Then developed tingling and burning sensation  of the feet and progressed to knee which intermittent type (on and off) 


No aggravating factors and relieved by rest .


Pedal Odema since 2 months inscidious in onset gradually progressive from grade 2 to 3 pitting type


No aggrevating factors relieved on rest 


C/o of passing hard stools once in 2 days on standing  non blood stained .

Past history

K/C/O HTN since 2 yrs

H/o cerebrovascular accident 1 year ago, catract surgery

N/K/C/O DM,TB,thyroid disorders,epilepsy,CAD,Asthma
No history of blood transfusions



Personal History

Married 

Daily wage labourer by occupation

Diet: mixed 

Appetite: lost

Bowel : irregular
bladder moments: normal

Addictions : beetle leaf  since 10 yrs and stopped 1 Yr ago

Family history

Not significant

Obstetric history
Age of marriage: 16 yrs
1st child birth: 18 yrs 
G3P3L2A0

Physical examination

On examination

Patient is conscious,coherent and cooperative well oriented to time,place,person 

No signs of pallor,icterus,clubbing,cyanosis,lymphadenopathy,pedal oedema 








Vitals

Temp: afebrile

PR: 98

Rr: 20/ min

Bp:120/90 mm Hg. 

Spo2: 98%

Systemic examination

CVS: S1,S2 heard, no murmurs heard 

Resp: BAE +

CNS :NAD 

Abdomen: soft and non tender
Shape:obese



Investigations:















Provisional diagnosis:

Peripheral neuropathy with acid peptic disease with pedal oedema with constipation. 


Treatment:

Tab.TELMA 40mg OD 
Tab.RAZOPRAZOLE -D 40mg OD
Tab.ECOSPRIN GOLD 20mg
Tab.PREGABALIM 75mg
Syp.CREMAFFIN 15ml
 


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