MKSAP: 42-year-old man with severe burning and stabbing pain

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 42-year-old man is evaluated for a 6-day history of severe burning and stabbing pain in both feet that is worse in the toes. The pain is more severe at night, is aggravated when the bed sheets touch his skin, and is partially relieved when he walks or massages his feet. The patient has an 8-year history of poorly controlled type 1 diabetes mellitus and a 2-year history of hypertension. He was hospitalized briefly 2 weeks ago for treatment of pneumonia and diabetic ketoacidosis. His fasting blood glucose levels have been in the range of 150 to 200 mg/dL (8.3-11.1 mmol/L) since hospital discharge. He does not drink alcohol or smoke. Medications are insulin glargine, insulin glulisine, and lisinopril. On physical examination, vital signs are normal; BMI is 22. Both feet and ankles are exquisitely sensitive to touch and temperature, especially on the tips of the toes. Pulses are easily palpated in both feet. No fasciculations, muscle weakness, foot ulcers, or foot deformities are noted. Monofilament testing reveals insensate feet bilaterally. Ankle reflexes are absent bilaterally. Results of laboratory studies show a HbA1c value of 9.2%. In addition to improving glycemic control, which of the following is the most appropriate next step in management? A. Desipramine B. Fluoxetine C. Nerve conduction studies D. Oxycodone E. Sural nerve biopsy Continue reading ... Your...
Source: Kevin, M.D. - Medical Weblog - Category: Journals (General) Authors: Tags: Conditions Diabetes Endocrinology Neurology Source Type: blogs