27-05-2025
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[27-05-2025 11.51] PPM 1: OPD now:
66M with metabolic syn diabetes 30 years.
Used to be a cutting master tailor but over last one year his customers have reduced as he's unable to cut properly!
On examination:
Glove and stocking anesthesia with loss of joint position sense
Impaired tandem walking
Broad based gait
Lives with wife. Son died recently. Unable to even afford their meals properly. Can't afford to get any further testing.
[27-05-2025 15:08] PPM 3: *Diagnosis and Management Plan for 66M with Long-Standing Diabetes and Neurological Symptoms*
*Clinical Presentation:*
- *Neurological Findings:* Glove-and-stocking anesthesia, loss of joint position sense, sensory ataxia (impaired tandem walking, broad-based gait).
- *Social Context:* Financial hardship, food insecurity, recent bereavement, inability to afford testing.
*Key Considerations:*
1. *Diabetic Peripheral Neuropathy (DPN):* Likely contributor to glove-and-stocking anesthesia. Chronic hyperglycemia damages sensory nerves, particularly large fibers mediating proprioception.
2. *Vitamin B12 Deficiency:* Suspected due to dorsal column involvement (proprioceptive loss, sensory ataxia). Risk factors include age, malnutrition, and potential malabsorption.
3. *Socioeconomic Factors:* Poverty exacerbates nutritional deficiencies and limits access to care.
*Differential Diagnosis:*
- Diabetic sensory neuropathy with large-fiber involvement.
- B12 deficiency (subacute combined degeneration).
- Combined etiology (DPN + nutritional deficiency).
*Management Strategy:*
1. *Empiric B12 Supplementation:*
- *Intramuscular B12 (1,000 mcg daily for 1 week, then weekly for 4 weeks, then monthly)* if available, as it bypasses absorption issues. If not, high-dose oral B12 (1,000–2,000 mcg daily).
- *Multivitamin:* Include folate and thiamine to address potential broader deficiencies.
2. *Diabetes Optimization:*
- Review current regimen (e.g., metformin, which can lower B12; consider supplementation if used).
- Low-cost dietary adjustments (prioritize protein/vegetables; connect with food banks).
3. *Symptom Management:*
- *Neuropathic Pain:* If present, low-dose amitriptyline (10–25 mg nightly) or gabapentin (if affordable).
- *Fall Prevention:* Provide a cane/walker via community programs; home safety assessment.
4. *Social Support:*
- *Food/Financial Aid:* Refer to local NGOs, government assistance, or religious organizations.
- *Grief Counseling:* Connect with free community mental health services.
5. *Low-Cost Diagnostics (if feasible):*
- *Complete Blood Count (CBC):* Screen for macrocytosis (B12/folate deficiency).
- *HbA1c:* Assess glycemic control.
*Follow-Up:*
- Monitor for improvement in gait/proprioception over 2–3 months (B12 response).
- Reassess neuropathy progression and social needs regularly.
*Critical Action Points:*
- Address immediate nutritional deficiencies (B12, protein-energy support).
- Leverage community resources to mitigate financial/emotional stressors.
- Simplify treatment to ensure adherence and affordability.
*Prognosis:*
- Partial neurological recovery is possible with B12 repletion.
- Early social intervention may improve quality of life and diabetes outcomes.
This approach balances diagnostic suspicion with pragmatic, resource-sensitive interventions to address both medical and social determinants of health.
[27-05-2025 16:26] PPM 1: 👏👏
[27-05-2025 16:27] PPM 3: DeepSeek 👆
[27-05-2025 16:28] PPM 1: Deepseek with some perplexity functionality would also be a winning combo.
[27-05-2025 16.29] PPM 3: These days AI studio is a good adjuvant.
[27-05-2025 22:02] PPM 2: Unsure if Broad based? Tandem seems okay sir?
[27-05-2025 22:02] PPM 2: Sensory Large fiber Axonal Neuropathy?
[27-05-2025 22:09] PPM 1: Yes interesting variations. One would expect broad based gait with rhombergs positive in a patient with absent joint position sense but it doesn't always happen
[27-05-2025 22:10] PPM 2: Swaying with closed eyes or open eyes too?
[28-05-2025 07:14] PPM 1: Minimal swaying with closed eyes
[28-05-2025 08:38] PPM 3: The absence of a broad-based gait or a positive Romberg's sign in patients with impaired joint position sense (proprioception) can be puzzling but is explained by several compensatory mechanisms and clinical nuances:
### 1. *Compensation via Vision*
- Patients often rely heavily on visual feedback to compensate for proprioceptive deficits. By watching their feet and surroundings, they can stabilize gait and posture. However, this compensation collapses in darkness or when eyes are closed (as in the Romberg's test), which is why a *"vision-dependent" gait* may mask ataxia until visual input is removed.
### 2. *Partial vs. Complete Proprioceptive Loss*
- *Incomplete lesions*: Mild or patchy proprioceptive loss (e.g., early-stage neuropathy) may allow residual sensation to guide movement, reducing the need for a wide-based gait.
- *Central vs. Peripheral Lesions*: Dorsal column (spinal cord) lesions (e.g., vitamin B12 deficiency) often cause severe sensory ataxia, while peripheral neuropathies (e.g., diabetic neuropathy) may spare proximal proprioception, enabling better compensation.
### 3. *Intact Motor and Cerebellar Systems*
- Strong motor strength and intact cerebellar function allow patients to stabilize movements despite sensory deficits. For example, cerebellar-driven "error correction" may dampen unsteadiness.
- Conversely, *sensory ataxia* (e.g., tabes dorsalis) classically presents with a "stomping" gait (slapping feet to enhance tactile feedback) and a positive Romberg’s sign, but these signs may be subtle early on.
### 4. *Adaptive Strategies*
- Patients may subconsciously adopt a cautious, slow gait with shorter steps, reducing the instability that would otherwise necessitate a broad base.
- Use of assistive devices (canes, walls) can mask gait abnormalities during clinical observation.
### 5. *Romberg’s Test Variability*
- A "positive" Romberg’s sign requires significant sway or falls upon eye closure. Some patients may sway minimally or recover quickly, leading to ambiguity.
- Testing conditions (e.g., uneven surfaces, examiner experience) also influence results.
### 6. *Lesion Localization*
- *Cortical or subcortical lesions* affecting proprioceptive integration may present differently than peripheral nerve or dorsal column damage. For example, parietal lobe lesions can cause sensory ataxia without Romberg’s positivity if other pathways compensate.
### Clinical Implications:
- *False Negatives*: A patient with proprioceptive loss but no Romberg’s sign or broad-based gait warrants evaluation for compensatory strategies or incomplete lesions.
- *Mimics: Cerebellar ataxia (wide-based gait regardless of vision) and vestibular dysfunction (falls *toward the affected side) must be ruled out.
- *Chronic Adaptation*: Over time, patients may develop remarkable compensatory habits, masking deficits until formally tested (e.g., tandem gait or standing on foam).
In summary, proprioceptive loss doesn’t always manifest classically due to the nervous system’s plasticity and redundancy. A thorough exam—including tandem walking, proprioceptive testing (toe/finger position sense), and provocative maneuvers (eyes closed on foam)—can uncover subtle deficits. Always contextualize findings with history (e.g., diabetes, alcoholism, vitamin deficiencies) and ancillary tests (nerve conduction studies, MRI).[DeepSeek]
[28-05-2025 08:55] PPM 1: 👏👏 provides an interesting idea for a project on "Testing sensitivity and specificity of detecting large fibre neuropathy as well as posterior column involvement in susceptible cohorts!" What says @Meta AI
[28-05-2025 08:55] Meta AI: That sounds like a fascinating project! 🤔 Large fibre neuropathy typically affects the larger nerve fibers responsible for vibration, proprioception (position sense), and motor functions. Posterior column involvement would relate to the dorsal columns of the spinal cord, which are crucial for transmitting sensory information like vibration and proprioception to the brain.
To test sensitivity and specificity for detecting these conditions, your project could involve:
1. Cohort selection: Identify susceptible cohorts, such as diabetic patients or those with vitamin deficiencies (e.g., B12), who are at risk for neuropathy.
2. Diagnostic methods: Utilize nerve conduction studies (NCS), electromyography (EMG), and/or quantitative sensory testing (QST) to assess large fibre neuropathy. For posterior column involvement, you might use MRI or clinical assessments like Romberg's test.
3. Data analysis: Calculate sensitivity (true positive rate) and specificity (true negative rate) for each diagnostic method, comparing them against a gold standard or clinical diagnosis.
4. Statistical considerations: Ensure adequate sample size and consider factors like inter-rater reliability and test-retest variability.
Some potential research questions to explore:
- Which diagnostic methods are most sensitive and specific for detecting large fibre neuropathy and posterior column involvement?
- How do these methods perform in different susceptible cohorts?
- Can combining multiple diagnostic approaches improve detection rates?
What specific aspects of this project would you like to focus on or explore further?
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