Case Study: Working Through The Differential Diagnosis Of Diabetic Neuropathy
Given that neuropathy can have a complex range of manifestations, the diagnosis of the condition is not always as obvious as it initially seems. This author emphasizes the importance of a thorough diagnostic workup and the underappreciated value of communicating with the patient.
When a 62-year-old minister got a referral to see a podiatric physician for neuropathic pain and dystrophic, “dry” changes to his feet, he noted his frustration with previous physicians. He said he felt like “one of those lab rats that has been given one drug and then another and another, hooked up to wires, run through mazes, given tests and then put through it all over again just to see if it comes out different the next time. Only it just seems to get worse, not better.”
It was not a role the minister would have picked for himself. He was planning for his retirement in a couple of years when he started noticing the first symptoms — the burning, tingling pain in the toes and hands — especially at night when he was trying to fall asleep. His primary care physician (PCP) had at first linked it to his type 2 diabetes. His blood sugar had always been slightly high as his HgA1C is in the 7 to 7.5 range.
The usual medicine regimen for diabetic neuropathy did not seem to work well for the minister’s pain and his PCP decided to focus on controlling his blood sugars more closely in addition to the other treatments. In the interim, she consulted the podiatrist for his input as a precaution.
The patient reported in his past medical history what he had just reported to other specialists as well. There were some new symptoms that were now threatening his last years in the pulpit. The minister was starting to not remember his sermons, or for that matter, remember his parishioners, some of whom he had known for decades. He struggled for common words, even in this appointment.
“Doctor, I walked up to the, uh, the … well, you know, the place where I stand to give my sermon. You know, that piece of furniture where I stand. The … oh gosh, I tell you I just cannot come up with words anymore.” The patient was obviously completely frustrated that he could not remember a simple word like “lectern,” a word he had used commonly.
Frankly, he was beginning to panic and he was filled with questions. Could this be related to his diabetes? Could out of control blood sugar cause mental changes and the foot pain?
The podiatrist decided to take a step back, do a detailed past medical history and leave no stone unturned. The DPM wanted to review all of the lab work, the tests that had been ordered by others and determine if he needed to order any other tests to complete the picture. Then the DPM would do his examination. This would be a long visit.
The patient was appreciative of the time the physician was taking with him. This was not the average 20-minute in-and-out visit. Sometimes, however, it was necessary to clear the appointment book in order to get to the bottom of a medical mystery. Otherwise, the patient continues to get worse, physicians continue to order unnecessary tests and unneeded referrals continue to be made.
It was fortunate for the doctor and the patient that this was the last appointment of the day. Realistically, the podiatrist knew that if it had not been the last appointment of the day, he would not normally have the luxury of taking this extra time with this complicated patient.
How The Past Medical And Social History Can Be Illuminating
The minister had been quite healthy over his 62 years. His diet was largely guided by his religious beliefs. As a Seventh Day Adventist, he was a vegetarian but he was well fed. If it had not been for his love of rich desserts and his wife’s good cooking, he would have been a very fit man.
At 5’8”, the minister carried 210 pounds on his frame but he was not a sedentary man. He and his wife stayed busy and were physically active. They went to the YMCA to exercise together at least three times per week. They enjoyed the social activity as well as the physical activity. They stopped going though when he had started feeling bad.
“Had the burning pain caused you to stop exercising?” the podiatrist asked him.