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Confused about diagnosis of Diabetic Neuropathy

Discussion in 'General Issues and Discussion Forum' started by footdrcb, Feb 22, 2011.

  1. footdrcb

    footdrcb Active Member


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    I was referred a patient today and their GP was insitent in the letter that they had diabetic neuropathy. (aged 72)
    The patient complained of burning during the night, occasional pins and needles, minor interuptions to balance and some discomfort in the gastrocs when walking up hills. (History revealed no cardiac complications).

    However,
    Monofilament, vibratory, and vascular testing all were within normal limits. Skin and hair growth on the feet appeared very good for a man of 72.
    The patient also underwent major abdominal/ spine surgery some 30 years ago. And a bilateral knee replacement 2 years ago , which is around the time the neuropathic symptoms appeared.

    I have never seen a patient who complains of all the symptoms, yet, illicits results within the normal range.

    Has anyone any thoughts on this enigma ??
    Thanks in advance

    FDCB
     
  2. Re: Confused !!!!!

    Got to wonder if this is the cause of the symptoms - some nerve damage during the replacement.

    GP sees diabetic with the following -The patient complained of burning during the night, occasional pins and needles, minor interuptions to balance and some discomfort in the gastrocs when walking up hills.

    bingo = neuropathy

    could be that this patient has diabetes but the cause of the symptoms was nerve damage/stress during the knee replacements, so certain things walking or pressure from lying on his back stress the nerve andsymptoms appear.
     
  3. davidh

    davidh Podiatry Arena Veteran

    Re: Confused !!!!!

    Got to agree with Mike on this one.

    Given the symptoms (but not the gastroc pain when walking uphill) two other things spring to mind- pernicious anaemia and medication interaction or side-effects. I'm guessing you've already considered these?
     
  4. Re: Confused !!!!!

    Yeah, painful neuropathy. Personnaly I have zero confidence in neuro testing so I'm not surprised.

    You need to find out if it's DM neuropathy of traumatic. If it's the former then try them on gabapentin. I've had lots of success with that. It's also diagnostic.
     
  5. footdrcb

    footdrcb Active Member

    Re: Confused !!!!!


    Mark, That was the way my "gut" was going. Im just not sure on this one. Thanks for your comment
    Craig :eek:
     
  6. footdrcb

    footdrcb Active Member

    Re: Confused !!!!!

    No I had not considered either of those to be honest. Ill have a look at both...

    thanks for your help......appreciate it greatly.

    Craig :eek:
     
  7. footdrcb

    footdrcb Active Member

    Re: Confused !!!!!

     
  8. Re: Confused !!!!!

    Somewhere I have a case study of a patient with perfect 10g monofilament sensation and a massive (probed about 3or 4 inches) painless, neuropathic ulcer!

    What's the point of a test if a negative result does not always indicate a lack of neuropathy.
     
  9. cornmerchant

    cornmerchant Well-Known Member

    Re: Confused !!!!!

    As you mention previous surgery , is it worth looking at Complex Regional Pain Syndrome? Probably unlikely as you are talking about pain in both legs, but just a thought. (previously called reflex sympathetic dystrophy).

    Regards
    CM
     
  10. footdrcb

    footdrcb Active Member

    Re: Confused !!!!!

    Good point..!!!
     
  11. footdrcb

    footdrcb Active Member

    Re: Confused !!!!!

    Thanks for the advice...I appreciate it ...Hey, did not know RSDS had been renamed....Im surprised they didn't throw the word "digital" in there somewhere..

    Regards

    FDCB
     
  12. blinda

    blinda MVP

    Re: Confused !!!!!

    I`m sure I have a copy of that, if not a similar, case study.

    A 10g monofilament is not diagnostic of neuropathy, it is only part of a large diagnostic armamentarium for assessing vulnerable areas, which could lead to ulceration, due to absence of protective sensation. I`ll try and dig out a paper which discusses the monofilaments` potential to detect neuropathic lesions, but not necessarily painful neuropathy.
     
  13. Re: Confused !!!!!

    I just don't see the point! You have to assume a diabetic COULD be neuropathic regardless of the test result so the advice has to be the same, that they COULD have neuropathy so they must work on the basis that they do.

    If the advice is the same regardless why do we bother?!

    Cheers
    Attouney at law for Mr B El-zebub.

    (I know we've been around this stump before missy.;))
     
  14. davidh

    davidh Podiatry Arena Veteran

    Re: Confused !!!!!

    If it was RSD you would see it in the foot/ankle. Joint ROM is restricted, the foot is cool or cold to the touch and the skin is mottled. I've seen a couple of cases, and they are unmistakable. As CM has already mentioned, it is also a unilateral disorder.
     
  15. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Re: Confused !!!!!


    Because all 'tests' have a false positive and false negative rate, and varying degrees of sensitivity and specificity.

    Currently, for screending purposes to detect loss of protective sensation, the 10g monofilament is considered to have established and validated accuracy and reliability.

    What it won't so is establish the difference between different forms of neuropathy, or subclinical nerve disease. Like all tests, it has its limitations.

    It runs a close second to my favourite, the "5 cent bone scan" (probe to bone test) - which has only fair to reasonable sensitivity and specificity.That's when you brain must take over. There are no fool proof guarantees with this medicine stuff.

    LL
     
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