Week 1 - Burning pain at bottom of feet

Question 1

Mr. Smith, 52y Caucasian male, ‘burning pain at the bottom of both of his feet’.

Take a history of this patient.

HPC:
• Since 4 months, constant, no radiation, worse at night (touch of bed sheets) - make you think what if worse on walking, rest, raising the leg or dependency position.
• Overweight, bad diet, hungry and thirsty all the time (pathogenesis of this?).
• Nocturia, no pain, dribbling or haematuria.
• Itchy rash in groin - Candida infection both groins (importance of this?)
• Tired, no energy, “I am slowing down.”
• Hypertension 4 years* - captopril.
• Mother and grandfather - diabetes. Dad died of MI at 54y (significance?)
• Smoker 20/day, social drinker, no drugs.
• P/E: LL loss of sensation bilateral, no vibration sense in big toe.

Answer 1

Age, gender, weight (i.e. obese)?

HPC:
• Site - where is the pain?
• Onset - when did the pain start?
• Character? i.e. burning.
• Localised or radiate?
• Alleviating factors?
• Timing - experienced it before? Constant or intermittent? How long does it last/worse at a particular time?
• Exacerbating factors?
• Severity?
• Associated symptoms? i.e. tired, no energy, hungry, thirst, polyuria, erectile dysfunction?
• Effect on lifestyle?

• Any signs of infection/rash?
• IHD - dyspnoea on exertion?
• PVD - claudication, 5Ps?
• Weight loss, fatigue, loss of appetite?
• Dysuria, incontinence/dribbling?
• Moods/well-being?

PMHx:
• Past history of any diabetes, cancer, cardiovascular disease, hypertension, dyslipidaemia etc?

PSHx:
• Any past surgeries?

Medications:
• Any regular medications?

Allergies:
• Agent, reaction, treatment?

Immunisations:
• E.g. Fluvax, pneumococcal?

FHx:
• Family history of any diabetes, cancer, heart disease etc?

SHx:
• Background?
• Occupation?
• Education?
• Religion?
• Living arrangements?
• Smoking?
• Nutrition?
• Alcohol/recreational drugs?
• Physical activity?

Systems Review:
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI - vomiting, diarrhoea, change in bowel habit?
• UG - dysuria, polyuria, nocturia, haematuria, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision?
• ENDO - heat/cold intolerance, swelling in throat/neck, polydipsia or polyphagia?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - painful or stiff joints, muscle aches or rash?

Question 2

Perform a physical examination on this patient.

Answer 2

1. Introduction, explanation, consent, wash hands.
2. General inspection: consciousness, body habitus (obesity or weight loss), central adiposity, pigmentation (haemochromatosis), endocrine facies (Cushing’s, acromegaly - big jaw/hands), injection sites (lower part of abdomen, upper part of thigh), ulcers, swellings, ketone smell on breath.
3. Vital signs:
   - HR
   - RR - tachypnoeic.
   - BP - postural variation.
   - Temp
   - Height, weight, BMI, BSL.
4. Legs:
   • Inspection
5. Structural foot deformity - bunions, hallux valgus, pes-cavus, claw toes, loss of transverse arch.
6. Vascular - pedal oedema, thin atrophic and shiny skin, loss or absence of hair, thickened nails, venous stasis changes and skin discolouration.
7. Infection - fungal nail infections, look in between toes, boils, cellulitis.
8. Neuropathic - dry skin, calluses and ulcers, neuropathic (Charcot’s joint), wasting of quadriceps.
9. Specific skin manifestations of diabetes - necrobiosis lipoidica diabeticorum, diabetic dermopathy (pigmented scars over shin), injection sites for fat atrophy or hypertrophy.
   • Palpation
   - Temperature, pulses in foot, CRT.
   - Sensation - light touch (rate score), cotton wool, vibration sense (128 Hz tuning fork), pain, proprioception - test on sternum, eyes closed.
   - Motor - bulk (check for wasting of quadriceps/gastrocnemius), movement (power and range of movement at hip, knee and ankle), reflexes (knee, ankle and plantar).

5. Hands/arms:
• Skin lesions and injection sites.
• CRT.
• Xanthomata.
• Discolouration, pallor (palmar creases).
• Acanthosis nigricans.

6. Face:
   • Eyes - xanthelasma, conjunctival pallor, jaundice (due to hepatomegaly), eye exam checking vision (Snellen), EOM for cranial nerve palsies (H shape with index finger - 3rd nerve common), fundus examination for diabetic and hypertensive retinopathy.
   • Mouth - infection especially candida, fetor, hydration.
7. Neck:
   • Acanthosis nigricans (also in the axillae and inguinal folds) indicates hyperinsulinemia.
8. CVS:
   • Carotids for bruits and signs of hypertension. Lung examination for infection.
9. Abdomen:
   • Inspect injection sites, check for hepatomegaly, tenderness due to fatty liver or haemochromatosis.

Question 3

What is your provisional diagnosis and differential diagnoses?

Answer 3

• Provisional diagnosis: Type 2 diabetes mellitus with neuropathy.
• DDx:
- Alcohol - thiamine deficiency.
- Cancer.
- Syndrome X (metabolic disorder).
- B12 deficiency.
- BPH (enlarged prostate).
- PVD.
- Mental health.
- UTI.
- Diabetes insipidus.
- Morton neuroma* (more common in females).

Question 4

What investigations would you carry out on this patient?

Answer 4

• FBC.
• U+Es.
• LFTs.
• BSL.
• Urine dipstick.
• B12/folate.
• HbA1c.
• Lipids.
• ECG.

Question 5

What treatment does this patient require?

Answer 5

• Pharmacological and non-pharmacological - start on medications as well as lifestyle modifications.
• Need regular follow up with GP.

Medications:
• Metformin - if not tolerated, another drug can be used. Rather then increasing dose too high, add another drug.
• Statin.
• Aspirin.
• Aim to maintain good control of BP first through lifestyle modifications. If BP does not come down → add another drug.

Lifestyle modifications:
• Quit smoking.
• Limit alcohol intake.
• Improve diet.
• Exercise (30 mins, 5 days a week).

Multi-disciplinary approach:
• Podiatry - diabetic foot care.
• Nutritionist - establish healthy diet.
• Optometrist - visits are usually every 2 years. The patient is showing signs of neuropathy, therefore most likely has retinopathy → needs an immediate visit.
• Diabetes educator - explain condition and how to best manage it.
• Exercise physiologist - exercise plan.
• GP care plan - regulates podiatrist and optometrist visits.