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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Assess the signs and symptoms of diabetic neuropathy

  • List the goals of treatment for patients with diabetic neuropathy

  • Select appropriate nonpharmacologic and pharmacologic treatment regimens for patients presenting with diabetic neuropathy

  • Develop a monitoring plan that assesses the safety and efficacy of the patient's diabetic neuropathy management

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PATIENT PRESENTATION

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Chief Complaint

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"My feet are on fire and I cannot sleep."

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History of Present Illness

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Andrew Carter is a 60-year-old African-American male with type 2 diabetes who presents to your ambulatory care clinic with burning pain in both feet. He reports that "nothing has helped, even the medication I took for surgery last year." The pain has worsened over the past several months and is preventing him from falling asleep. Patient also says that in the past he could eat anything put in front of him, but lately he has been nauseated and felt full with a small amount of food. When asked, patient says that he takes all of his medicine at the same time on an empty stomach.

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Past Medical History

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Type 2 diabetes diagnosed at age 39

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Benign essential HTN diagnosed at age 44

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Dyslipidemia diagnosed at age 39

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ACL surgery 1 year ago

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Family History

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Father had HTN and died from a stroke at age 67

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Mother is alive at age 82 and has HTN and asthma

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Sister is alive at age 57 with a history of asthma

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Social History

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Widowed 2 years ago, lives alone and is working at a grocery store. Son and daughter-in-law live out of state.

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Tobacco/Alcohol/Substance Use

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(−) alcohol, but he does smoke 2 ppd of cigarettes.

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Allergies/Intolerances/Adverse Drug Events

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Lisinopril: Cough

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Medications (Current)

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Aspirin 81 mg daily

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Insulin glargine 10 units daily

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Losartan 100 mg daily

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Metformin 500 mg twice daily

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Pravastatin 40 mg daily

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Diphenhydramine 50 mg daily at bedtime as needed (has used over the past several days without relief)

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Medications (Prior)

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Was on glipizide and metformin when he was first diagnosed, but insulin was started 3 months ago.

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Review of Systems

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Feet: (+) paresthesia (burning, tingling) and allodynia that is worse at night, (−) for ulcer, cuts, sores, or deformities, (+) dry skin. (+) nausea and bloating, (+) for insomnia, (−) chest pain, SOB or dizziness.

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Physical Examination

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General
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The patient ...

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