Diabetic Neuropathy

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Case:

HPI: 51yo man with a PMH of Type 2 Diabetes Mellitus presents with complaints of polydipsia, polyuria, and burning and tingling of the legs.

PMH: Type 2 Diabetes and Hypertension

PSH: Appendectomy, Hemmorrhoidectomy

Allergies: none

MEDS: Gabapentin 300mg tid

Insulin 70/30  30u in AM, 15u in PM

PE: Temp 98.4, HR 100, BP 128/90, Wt. 132

Thin black male, with an unremarkable exam

Ext: no edema, ulcerations, or deformities

Neuro: strength: 5/5 all extremities

reflexes: absent Achilles bilaterally

sensation: diminished to light touch below ankle

Labs: fingerstick glucose 250

Hgb A1c 15.7%

Assessment: Uncontrolled diabetes with signs of neuropathy

Plan: Optimize glycemic control, refer to diabetes education, evaluate for other late complications such as retinopathy (optho) and nephropathy (microalbumin) and…

Diabetic Neuropathy 

It is  the most common of all the late complication of diabetes mellitus.

Definition according to the San Antonio Conference on Diabetic Neuropathy 1988:

  “Diabetic neuropathy is a descriptive term meaning a demonstrable disorder, either clinically evident or subclinical, that occurs in the setting of diabetes mellitus without other causes for peripheral neuropathy.  The neuropathic disorder includes manifestations in the somatic and/or autonomic parts of the peripheral nervous system.”

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Classification and clinical features:

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Electrophysiologic studies reveals:

  • NCV demonstrate demyelination and axonal degeneration in the form of decreased amplitudes of the compound muscle action potential and sensory action potential.
  • The earliest finding is distal slowing of conduction with preservation of proximal NCV.
  • EMG reveals denervation and reinnervation

D/D:

  • Metabolic etiologies: B12/ folate deficiency, hypothyroidism,uremia
  • Toxic etiologies: ETOH, heavy metals, medications
  • Inflammatory etiologies: vasculitis, sarcoid, SLE, syphilis, leprosy
  • Other: paraneoplastic, leukemia, amyloid

Management:

  • Prevention of neuropathy through tight glycemic control, goal is to achieve “normal” levels
  • Control of neuropathic pain

-Simple analgesics (acetaminophen, NSAIDS)

-Tricyclic antidepressants

-SSRIs

-Anticonvulsants

-Mexilitine

-Tramadol

              -Alternate therapies: Electrical spinal cord stimulaion, Acupuncture

  • Prevention of foot complications:

-Keep their feet clean and dry at all times

-Never walk barefoot

-Avoid high impact exercise (esp w/deformities)

-inspect their feet daily for calluses, infections, abrasions, or blisters.

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