Case Report

General Data:
TL. 53yo, female, married, Filipino, catholic, housewife, currently residing at
Balintawak, Quezon City, born on May 07, 1963 at Samar Leyte, consulted for the 1 st time in our
institution on October 19, 2016.

Chief Complaint:
Namamanhid ang kamay, paa at likod

History of Present illness:

2 months prior to consult patient experience pamamanhid of forearm, legs and back,
which is said to happen only every night and said to have short in duration approximately 1min.
no associated symptom such as pain, weakness, stiffness, joint pains. No medications here taken,
and no consultation was done. Due to persistence of symptoms patient decided to seek consult

Past Medical History:

Patient has unrecalled childhood vaccination and claimed to not have had chicken pox,
measles, or mumps. Patient is hypertensive and has maintenance of Losartan 50mg and
Amlodipine 10mg. She is non-diabetic, no history of asthma, pulmonary tuberculosis, kidney and
liver disease; had history of thyroid disease and underwent thyroidectomy in 2010 treated. No
other hospitalization noted. No known allergies of food nor drug.

Family History:
Patient has a family history of hypertension, diabetes mellitus, on both paternal and
maternal side and thyroid disease only on maternal side but without asthma, pulmonary
tuberculosis, kidney disease, liver diseases nor malignancy.

Personal Social History:

Patient is eldest among 4 siblings, an elementary graduate, housewife, married to a 57
year old labor foreman, with 3 children. Prefers wide variety of food. Patient consider her daily

household chores as a form of exercise like going to public market, cooking, doing the laundry,
playing with her grandchildren. Patient denies smoking and drinking alcoholic beverages. Lives
in a well-ventilated bungalo made of light materials with 4 occupants. Garbage is said to be
deposited at a nearby river.

OB History:
G3P3 (3-0-0-2)
G1 1983, FT baby boy NSD (-) FNC
G2 1988, FT baby boy NSD (-) FMC
G3 2001, FT baby boy NSD (-) FMC

Gyne History:
Menopause at age 50 y/o

Review of System:
General: (-) weight loss, (-) weight gain, (-) fatigue
Skin: (-) rashes, (-) itchiness, (-) discoloration
HEENT: (+) headache, (-) blurring of vision, (-) eye pain, (-) discharge, (-) tinnitus
Respiratory: (-) chest pain, (-) dyspnea, (-) cough, (-) colds
Cardiovascular: (-) orthopnea, (-) palpitation, (-) PND
GIT: (-) diarrhea, (-) constipation, (-) hematemesis, (-) melena
Hematologic: (-) pallor, (-) easy bruisability
Neurologic: (-) paralysis, (-) seizure, (-) tremors

Physical Examination
General survey
Conscious and coherent not in cardiorespiratory distress
Vital signs
BP: 120/70 PR: 76bpm RR: 19cpm T:36.6 HT: 156cm WT: 57kg BMI: 23 kg/m2
Skin

Skin is brown, warm, moist, good skin turgor, with good capillary refill of <2 sconds
HEENT
Anicteric sclera, pink palpebral conjunctiva, no nasoaural discharge no tonsilopharyngeal
congestion, no cervicolymphadenopathy
Chest and Lungs
Symmetrical chest expansion, no retraction, equal vocal fremitus, clear breath sounds
Cardiovascular
Adynamic precourdium, normal rate and rhythm, no murmur
Abdomen
Flat, normoactive bowel sound, soft, non-tender, tympanitic
Extremities
Grossly symmetrical, no cyanosis, no edma, full equal peripheral pulses
Central Nervous System
Cerebrum: Alert, oriented to time, place and person
Cerebellum: Able to do rapid, coordinated, alternating movement with ease
Cranial nerve: I-able to smell, II-20/25 OU, PERRLA, III,IV,VI- intact EOM, V-able to feel
light touch and clench teeth, VII-able to do facial expression(frown, smile), VIII-able to localize
and hear sounds, IX,X- uvuala is at midline, XI-shrug shoulder, XII-tongue is in the midline

1
Dix hallpike: (-) Nystagmus
Tilt test: Lying:110/70, Sitting: 120/70

Salient Features
50yo, female, married, Filipino, catholic, housewife, with a chief complaint of numbness
of the hands, forearm and back, is a known case of hypertension, highest BP 180/100, usual BP
3

120/70, currently taking losartan 50mg/tab OD AM and amlodipine 10mg/tab OD PM, s/p
thyroidectomy last 2010. BMI of 23 kg/m2, Positive for polyuria, polydipsia and polyphagia but
without weight loss. Vision is 20/25 OU.
Differential Diagnosis
Diagnosis
DM type 2

Rule in
Rule out
Numbness on the hand, Cannot totally
forearm and back

Electrolyte

out

request for FBS, OGTT,

Age
HBA1C
imbalance Numbness on the hand, Cannot totally

(hypokalemia,

forearm and back

hyponatremia, hypokalemia
AGD prob. OA

levels
Numbness on the hand, Cannot
forearm and back

rule

rule

out

request for serum Na, K, Ca

totally

rule

out

request for x-ray

Age
Assessment:
Hypertension stage II
Diabetes Mellitus Suspect
t/c peripheral neuropathy
t/c AGD prob OA

Plan:
Hypertensive work up CXR(PA), 12-L ECG, CBC, Urinalysis, BUN, Creatinine, Na, K,
Cholesterol, TAG, HDL, SGP, SGOT, FBS, HBA1C, OGTT
X-ray of both hands, forearm, back (APL)
Continue oral medications: Losartan 50mg/tab OD; AM
Amlodipine 10mg/tab, OD, PM
Start Vitamin B complex OD
Daily BP monitoring
IOFI
TCB once with result

Advised

10/21/16
Patient came back with the ff laboratory results:
ECG: Non-specific t wave cnahges
U/A: Yelllow, Hazy, (-) protein and sugar, pH: 6.0, spcfc gravity: 1.020, 2-4/ Hpf RBC, none
HPF pus cells, +2 leukocytes
CBC
59.4

119

5.71

7.8

35.4

27.8

431
4-8

FBS: 159 mg/dl

Na: 143.3 mmol/L

BUN: 7.3 mmol/L

K: 4.03 mmol/L

Crea: 0.85mg/dl

Calcium: 2.5 mmol/L

Uric Acid: 3.00 mg/dl

SGPT: 14.0 u/L

TAG: 83.6 mg/dl

SGOT: 19.0 u/L

LDL: 112.1 mg/dl

HDL: 65.132 mg/dl
Cholesterol: 193.8

Physical Examination
General survey
Conscious and coherent not in cardiorespiratory distress
Vital signs
BP: 120/70 PR: 76bpm RR: 19cpm T:36.6 HT: 156cm WT: 57kg BMI: 23 kg/m2
Skin
Skin is brown, warm, moist, good skin turgor, with good capillary refill of <2 sconds
HEENT
Anicteric sclera, pink palpebral conjunctiva, no nasoaural discharge no tonsilopharyngeal
congestion, no cervicolymphadenopathy

Chest and Lungs

Symmetrical chest expansion, no retraction, equal vocal fremitus, clear breath sounds

Cardiovascular
Adynamic precourdium, normal rate and rhythm, no murmur
Abdomen
Flat, normoactive bowel sound, soft, non-tender, tympanitic
Extremities
Grossly symmetrical, no cyanosis, no edma, full equal peripheral pulses
Central Nervous System
Cerebrum: Alert, oriented to time, place and person
Cerebellum: Able to do rapid, coordinated, alternating movement with ease
Cranial nerve: I-able to smell, II-able to read prints, III,IV,VI- intact EOM, V-able to feel light
touch and clench teeth, VII-able to do facial expression(frown, smile), VIII-able to localize and
hear sounds, IX,X- uvuala is at midline, XI-shrug shoulder, XII-tongue is in the midline

Assessment:
DM type 2
Hypertension stage 2 controlled

Plan:
Repeat FBS after 2 weeks
Continue oral medications: Losartan 50mg/tab OD; AM
Amlodipine 10mg/tab, OD, PM

Start Vitamin B complex OD

Metformin 500mg/tab BID AM and PM
Daily BP monitoring
Daily foot care
Refer to Ophthalmology
Refer to Dietary Department
IOFI
TLC
TCB after 2weeks with FBS result