CASE 8 - Diabetes Follow-Up

Question 1

Will I lose my feet, doctor?

4

Answer 1

1. Amputation is a last resort in patients with diabetes who develop an infection in their feet, and fortunately we are not at that point.
2. Nerve damage to your feet is uncomfortable, but it will not lead to amputation as long as you take proper measures to protect your feet from injury.
3. If we continue to keep your blood sugar and cholesterol well controlled, we should be able to avoid amputation.
4. We’ ll discuss more on how to do this later in the visit.

Question 2

Specific questions to ask:

Answer 2

1. Last checkup.
2. Compliance.
3. Last blood sugar reading — blood sugar monitoring — last A1C.
4. Last time eyes were checked.
5. Med side effects.

Question 3

PEx:

Answer 3

1. Eye exam ==> fundoscopic exam.
2. Neck exam ==> Carotid A.
3. CV ==> P + A.
4. Pulmonary exam ==> A.
5. Abdo exam ==> A + P + P.
6. Extremities ==> Inspected feet + peripheral pulses.
7. DTRs + Babinksi + sensation and strength in lower extremities.

Question 4

Sample closure:

Answer 4

1. Mr. Stern, the palpitations and sweating you have experienced are most likely due to episodes of low blood sugar, which may have resulted from a higher-than-normal dose of insulin or from skipping or delaying meals.
2. The numbness you describe in your feet is probably related to the effect of diabetes on your nervous system — better control of your blood sugar may help improve this problem.
3. Many factors, including diabetes, can cause the erection difficulties you describe.
4. I will need to perform an exam of your genital area and run some blood tests, and at some point we may also need to conduct some more complex tests to identify the cause of your problems.

DYHAQFM

Question 5

DDx 1 — Insulin-induced hypoglycemia:

Answer 5

1. Episodes of palpitations and diaphoresis that resolve with drinking orange juice.
2. Tight glycemic control.

Question 6

DDx 2 — Diabetic peripheral neuropathy:

Answer 6

1. Hx of DM.
2. Constant numbness and tingling in feet.
3. Absent ankle jerk.

Question 7

DDx 3 — Organic erectile dysfunction:

Answer 7

1. Loss of erection for 2y with absence of early-morning erection.
2. Hx of DM.
3. Hx of alcohol use.
4. Lovastatin + atenolol.

Question 8

Workup:

Answer 8

1. Genital exam.
2. Serum glucose + A1C.
3. UA, urine microalbumin, BUN/Cr.
4. Doppler US-penis.
5. Nerve conduction studies.

Question 9

Additional DDx:

Answer 9

1. Alcoholic peripheral neuropathy.
2. Multiple myeloma.
3. Renal failure.
4. Hypothyroidism.
5. Vasculitides.

Question 10

Things I forgot to ask:

Answer 10

1. Last time eyes were checked.
2. How are you feeling today?
3. Pulmonary complaints?
4. Marital or work problems?
5. Weight changes/appetite?
6. Hx of TIA or stroke.

Question 11

Forget in the workup:

Answer 11

1. Genital exam.

2. Nerve conduction studies.