Diabetic Peripheral Neuropathy
4 Personal history
A known diabetic patient محمد عبد الحميد 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.
4 c/o
Loss of sensation in both
hands and feet of 15 years duration.
4 HPI
The condition
started 15 years ago by nocturnal burning pain associated 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 walked on 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 diminution of
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.
4 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.
4 Family history
-
No similar
condition in family.
-
No consanguinity.
-
No common disease
in family.
4 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.
4 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.
4 Examination of Speech: Normal
4 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).
4 Examination of Motor
System :
4 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.
4 Examination of
Tone__
-
Bilateral symmetrical hypotonia in
both upper and lower limbs.
4 Percussion__
No fasciculation or myotonia.
4 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.
4 Coordination
Coordination cannot be
examined on both upper and lower limbs because of weakness.
4 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).
4 Back: No deformity, no swelling, no scars .
4 Gait: stamping (may be high steppage).
4 other system examination (search for autonomic
neuropathy):
1- 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).
2- Genitourinary:
-
Bladder
disturbances (incontinence à ask for it)
-
Impotence (psychic
and organic à ask for it)
3- Marked sweating specially with meals (gustatory sweating à ask for it )
4- Gastrointestinal:
-
Gastroparesis
diabeticorum (ask for dyspepsia).
-
Diabetic
enteropathy (ask for nocturnal watery diarrhea and constipation).
4 pathogenesis
Sorbitol pathway.
4 Investigation
-
For diabetes: Bl.
Sugar level with HBA1C, ECG, RFTs, blood lipid profile (cholesterol, HDL, LDL, TG)
-
For P.N: Nerve
Conduction velocity.
4 Treatment
-
For diabetes: tight
control.
-
For the P.N.: Tegretol,
gabapentin, vitamins, aldose reductase inhibitor
(disappointing results).
4 Diagnosis :
Diabetic
Peripheral Neuropathy
4 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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