NURS 6512 CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS

Patient Information:

Initials: J.P

Age- 48 years

Sex- Male

Race- Asian

S.

CC (chief complaint): “I cannot feel my toes in the left foot.”

HPI: J.P. is a 48-year-old Asian male patient presenting with a chief complaint of not feeling his toes on the left foot. The patient has a known history of diabetes mellitus type 2. He states that the symptoms began about two months ago, and he first ignored them. However, the problem has persisted, and he is concerned that he could end up with an amputated leg. He also reports experiencing numbness in the heel of the right foot and a tingling sensation.

Current Medications: Metformin 850 mg PO OD; Simvastatin 40 mg

Allergies: No drug/food allergies.

PMHx: Diagnosed with Type 2 Diabetes at 44 years; Hyperlipidemia; Obesity. Immunization is current. No surgical history.

Soc Hx: J.P. is an insurance agent with a Diploma in Sales and Marketing. He is married and has two children, 20 and 15 years. He smokes ½-1 PPD and drinks beer 3-4 bottles at least five times a week. He takes 3-4 meals a day and sleeps an average of six hours. His hobbies are traveling and watching soccer.

Fam Hx: The paternal grandfather died from Heart failure and had HTN and DM. The father died at 74 years from Kidney failure and had DM and HTN. The elder brother has a history of HTN. Children are alive and well.

ROS:

GENERAL:  Denies weight changes, fever, chills, increased fatigue, or malaise.

CARDIOVASCULAR:  Negative for chest pain, exertional dyspnea, palpitations, or edema.

RESPIRATORY:  Negative for shortness of breath, cough, wheezing, or sputum.

NEUROLOGICAL:  Positive for loss of sensation in the left foot, numbness in the right heel, and tingling sensations. Denies headaches, muscle weakness, or syncope.

O.

Physical exam:

Vital signs: BP- 136/84; RR-16; Temp-98.6; HR-80; HT-5’7; WT- 260 BMI-40.7

General: 48-year-old Asian male. The patient is morbidly obese. He is alert, calm, and in no distress. He is well-groomed and appropriately dressed. He is oriented X3 and maintains eye contact.

Cardiovascular: Regular heart rate and rhythm. S1 and S2 are present. No heart murmurs.

Respiratory: Symmetric chest expansion with smooth respirations. Lungs are clear on auscultation bilaterally.

Neurological:  Normal gait and posture.

Muscle strength 5/5. Reduced distal sensations in both feet. Decreased vibratory and pinprick sensation over the toes on the left foot.

Hypoactive Deep tendon reflexes.

Negative Tinel test.

Diagnostic results: The recommended diagnostic tests for this patient include:

Fasting blood sugar (FBS) to assess the blood glucose levels.

HbA1c to assess the patient’s glycemic levels in the past three months.

The two tests will assess for hyperglycemia that leads to neuropathy through blood vessel changes that cause nerve hypoxia (Galiero et al., 2023).

Nerve conduction studies (NCS) and electromyography (EMG): To assess the characteristics of the neuropathy, the localization, the severity, and the likely prognosis.

A.

Differential Diagnoses

1. Diabetic Diffuse neuropathy: This is the most common neuropathy in diabetic patients. It is characterized by widespread loss of nerve function. It has a slow onset, affects both sides of the body, affects motor and sensory nerves, advances slowly, is permanent, and includes autonomic nerve dysfunction (Fan & Gordon Smith, 2022). The differential is based on the patient’s complaints of loss of sensation in the left foot, numbness in the right heel, and tingling sensation. Besides, the patient had reduced distal sensations in both feet and decreased vibratory and pinprick sensations over the toes on the left foot.
2. Diabetic Focal neuropathy: This affects a single nerve or nerve group. It is usually caused by an acute ischemic event or by nerve trapping and leads to nerve damage or nerve death (Galiero et al., 2023). Positive symptoms of loss of sensation in the left foot, numbness in the right heel, and tingling sensation align with this differential.
3. Vitamin B-12 deficiency: The patient presents with clinical manifestations of peripheral neuropathy like reduced sensation and tingling sensations, which occur in Vitamin B-12 deficiency (Guéant et al., 2022).
4. Alcoholic Neuropathy: This is characterized by damage to nerves due to long-term excessive alcohol consumption. Clinical symptoms include spontaneous burning pain, painful sensations with or without burning quality, and weakness in the extremities (Julian et al., 2019). The patient’s neuropathy symptoms can be associated with his overindulgence in alcohol.
5. Tarsal tunnel syndrome (TTS): This is a neuropathy caused by compression of the posterior tibial nerve and its branches. Common symptoms included dysesthesia, paresthesia, numbness, tingling, and burning pain in the sole (Rodríguez-Merchán & Moracia-Ochagavía, 2021). The patient has a loss of sensation in the left foot, numbness in the right heel, and tingling sensation, making this a differential diagnosis.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Fan, Q., & Gordon Smith, A. (2022). Recent updates in the treatment of diabetic polyneuropathy. Faculty reviews, pp. 11, 30. https://doi.org/10.12703/r/11-30

Galiero, R., Caturano, A., Vetrano, E., Beccia, D., Brin, C., Alfano, M., … & Sasso, F. C. (2023). Peripheral neuropathy in diabetes mellitus: Pathogenetic mechanisms and diagnostic options. International Journal of Molecular Sciences, 24(4), 3554. doi: 10.3390/ijms24043554

Guéant, J. L., Guéant-Rodriguez, R. M., & Alpers, D. H. (2022). Vitamin B12 absorption and malabsorption. Vitamins and hormones, 119, 241–274. https://doi.org/10.1016/bs.vh.2022.01.016

Julian, T., Glascow, N., Syeed, R., & Zis, P. (2019). Alcohol-related peripheral neuropathy: a systematic review and meta-analysis. Journal of Neurology, pp. 266, 2907–2919. https://doi.org/10.1007/s00415-018-9123-1

Rodríguez-Merchán, E. C., & Moracia-Ochagavía, I. (2021). Tarsal tunnel syndrome: current rationale, indications, and results. EFORT open reviews, 6(12), 1140–1147. https://doi.org/10.1302/2058-5241.6.210031