Week 1- Burning pain at the bottom of the feet Flashcards
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 but covers whole sole of foot, worse at night (touch of bed sheets) - make you think what if worse on walking, rest, raising the leg or dependency position-> PVD.
• Overweight, bad diet, no exercise hungry and thirsty all the time (pathogenesis of this?).
• Nocturia, no pain, dribbling or haematuria (eliminating prostate cancer and nephropathy)
• Itchy rash in groin - Candida infection both groins (importance of this?)
• Tired, no energy, “I am slowing down.”
• Hypertension 4 years* - captopril. No OTC.
Hernia repair 8 years ago. Vaccination up to date.
• Mother and grandfather - diabetes. Dad died of MI at 54y (significance?)
• Smoker 20/day for 30 years, social drinker, no drugs.
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 (night or day), erectile dysfunction (autonomic dysfunction), weight gain, hunger? • Effect on lifestyle? -Have you noticed any wounds on your feet or legs? That aren't healing?
- 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? -Recent travel
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 (autonomic neuropathy)?
• UG - dysuria, polyuria, nocturia, haematuria, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision (retinopathy)?
• 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, back pain (sciatica)?
Perform a physical exam
- BMI 32
- Loss of vibration on big toe
- Loss of sensation bilaterally
- Reflexes are present but delayed
- Introduction, explanation, consent, wash hands.
- 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.
- Vital signs:
- HR
- RR - tachypnoeic?
- BP - postural variation?
- Temp
- Height, weight, BMI, BSL. - Legs:
• Inspection - Structural foot deformity - bunions, hallux valgus, pes-cavus, claw toes, loss of transverse arch.
- Vascular - pedal oedema, thin atrophic and shiny skin, loss or absence of hair, thickened nails, venous stasis changes and skin discolouration
- Infection - fungal nail infections, look in between toes, boils, cellulitis.
- Neuropathic - dry skin, calluses and ulcers, neuropathic (Charcot’s joint), wasting of quadriceps.
- 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- monofilament), 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.
- 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), opthalamascope for fundus examination for diabetic and hypertensive retinopathy.
• Mouth - infection especially candida, fetor, hydration. - Neck:
• Acanthosis nigricans (also in the axillae and inguinal folds) indicates hyperinsulinemia. - Need to look in groin at candidal infection
- CVS:
• Carotids for bruits and signs of hypertension. Lung examination for infection. - Abdomen:
• Inspect injection sites, check for hepatomegaly, tenderness due to fatty liver or haemochromatosis.
What is the provisional and ddx
Provisional diagnosis: Type 2 diabetes mellitus with neuropathy. • DDx: - Alcohol - thiamine deficiency. - Cancer - Syndrome X (metabolic disorder). - B12 deficiency-> parathesia - BPH (enlarged prostate). - PVD -Tarsal tunnel syndrome -Sciatica -Renal failure (uremia) - UTI. - Diabetes insipidus. - Morton neuroma* (more common in females-compression on nerve). -Psychogenic pain
What investigations would you perform
- BSL 29
- Urine dipstick- no leukocytes, 2+ sugar
- HbA1c 11%
- B12 and folate normal
- Cholesterol 7.5
- FBC.
- U+Es.
- LFTs.
- BSL.
- Urine dipstick (infection and microalbuminemia)
- B12/folate.
- HbA1c–> do not do OGT
- Lipids.
- ECG.
What treatment does the patient require
• Pharmacological and non-pharmacological - start on lifestyle modifications first, followed by medication
• Need regular follow up with GP- review after 1 month- keeps patient motivated with small achievable goals
-Repeat HbA1c, urinalysis, U&E, LFT, lipids after 3 months
Medications:
• Metformin - if not tolerated, another drug can be used. Rather then increasing dose too high, add another drug- sulfonyurea.
• Statin.
• Aspirin.
• Aim to maintain good control of BP first through lifestyle modifications. If BP does not come down → add another drug.
-Treatment for candidiasis
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.
What is the MOA of metformin
Activation of AMP-activated protein kinase (AMPK) →↑ of a nuclear receptor that inhibits expression of genes important for gluconeogenesis→Reduce hepatic glucose production, increase glucose uptake and utilisation in skeletal muscle (reduce insulin resistance), reduce carb absorption and increase fatty acid oxidation
What are the side effects of metformin
Heartburn, stomach pain, nausea or vomiting, bloating, gas, diarrhoea, constipation, weight loss
