Case 049: Diabetes and Pain

PATIENT PRESENTATION

Chief Complaint

“My feet feel like they are on fire and I cannot sleep as a result”

History of Present Illness

Luis Ramirez is a 47-year-old Puerto Rican male with type 2 diabetes who presents to your ambulatory care clinic with a burning sensation in both feet. He reports that “nothing has helped, even the medication I take for sleeping.” The pain has worsened over the past several months and is preventing him from falling asleep. Patient also says that in the last few months he has felt down and not himself.

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. What signs, symptoms, and physical exam data support the diagnosis of peripheral neuropathy?

   Hint: See Clinical Presentation and Diagnosis in PPP

2. What other diabetes-related neuropathies should be ruled out at this time?

   Hint: See Treatment in PPP

3. What indicators are present for depression?

   Hint: See Clinical Presentation and Diagnosis and Table 39-1 in PPP

4. What are the treatment goals for this patient?

   Hint: See Treatment and Outcome Evaluation in PPP

5. What would be the most appropriate course of treatment for this patient? Please address pharmacological and nonpharmacological aspects. For the pharmacological agent, please include dose, route, frequency and duration. Please explain your rationale. How would the presentation of peripheral neuropathy change in the setting of a sudden change in glycemic control?

   Hint: See Figure 35-2 and Tables 44-10 and 44-11 in PPP

FOLLOW-UP

How would the presentation of peripheral neuropathy change in the setting of a sudden change in glycemic control?

Hint: See Treatment and Outcome Evaluation in PPP.

CASE SUMMARY

Global Perspective

Peripheral neuropathy is one of the most common diabetic complications with a prevalence of 30-50%. Of these patients, up to 50% are asymptomatic. This prevalence increases in developing countries. Even in developed countries, peripheral neuropathies account for more hospitalizations than all other neuropathies combined and is a major risk factor for complications. Additionally, common prescribing patterns lag behind treatment guidelines. In one study, almost 40% of patients reported that they were never treated and 33% were treated with medications with no known efficacy for neuropathy symptoms.

Key References