Dr. Ajeet Singh (Family Medicine) needs a second opinion on this medical case.
60 year old male with paresthesia and numbness almost multiple areas of the body along with a history of DM, HTN
60 year old male presented to OPD with complaints of tinnitus both ear, accompanied with numbness over right half of face with lips too and occasional lacrimation from right eye. He also compalints of paresthesia over left thigh and left leg esp. upon getting up from chair and walking.
He also complaints of constipation and instability upon walking which I could attribute to Pregabalin
He is a known case of Hypertension and T2DM
He has had an attack of stroke in the past too
SPO2 - 99
PR - 60/min
ECG - WNL
He is currently on -
1) Tab Glimestar M1 BD
2) Tab Carbamazepine 100mg OD
3) Tab Pregabalin 75 mg HS
4)Tab Palminges once daily
5) Tab Nebilong AM once daily
Kindly comment what all changes needs to be instituted in the current regimen of treatment?
In my opinion, I would like to add him on Gingko Biloba + Piracetam combination for his tinnitus. Secondly, I would like to add him on Telmisartan plus Amlodipine combination for blood pressure instead of Nebilong AM.
Kindly give your valuable opinion on this case