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A 50-year-old man diabetic
Case 7
A 50-year-old man with “diet-controlled” diabetes is referred by his primary care provider for worsening
pain in his feet over the past year. He describes the symptom as a constant “pins and needles” sensation
primarily localized to the bottom of his feet, with burning pain in the same area, especially at night. He
has no symptoms in his hands. He takes no medications and does not monitor his blood sugars. His
diabetes was diagnosed five years ago.
Cranial nerves and motor exam are normal. There is moderate elevation of the vibratory thresholds in
the toes of both feet. Light touch is mildly impaired to the ankles and touch evokes an unpleasant
tingling sensation in the soles. Pain and temperature are reduced distally to both ankles. Sensory
examination is normal in the arms and hands. The deep tendon reflexes are absent at both ankles, and
normal elsewhere, with flexor plantar responses bilaterally. Gait is normal and Romberg is negative.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? Include doses
for one medication you might prescribe, along with an estimate of the cost of a month of your
proposed therapy. How would you counsel the patient about his condition and about any proposed
therapy?
A 50-year-old man diabetic
A 50-year-old man with “diet-controlled” diabetes is referred by his primary care provider for worsening
pain in his feet over the past year. He describes the symptom as a constant “pins and needles” sensation
primarily localized to the bottom of his feet, with burning pain in the same area, especially at night. He
has no symptoms in his hands. He takes no medications and does not monitor his blood sugars. His
diabetes was diagnosed five years ago.
Cranial nerves and motor exam are normal. There is moderate elevation of the vibratory thresholds in
the toes of both feet. Light touch is mildly impaired to the ankles and touch evokes an unpleasant
tingling sensation in the soles. Pain and temperature are reduced distally to both ankles. Sensory
examination is normal in the arms and hands. The deep tendon reflexes are absent at both ankles, and
normal elsewhere, with flexor plantar responses bilaterally. Gait is normal and Romberg is negative.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.A 50-year-old man diabetic.