My left foot feels weak and numb. I have a hard time pointing my toes up

Patient Case #1

CC: “My left foot feels weak and numb. I have a hard time pointing my toes up.”

HPI: C.B. is a significantly overweight, 48-year-old woman from the Winnebago Indian tribe who had high blood sugar and cholesterol levels three years ago but did not follow up with a clinical diagnostic work-up. She had participated in the state’s annual health screening program and noticed that her fasting blood sugar was 141 and her cholesterol was 225. However, she felt “perfectly fine at the time” and could not afford any more medications. Except for a number of “female infections,” she has felt fine until recently.

Today, she presents to the Indian Hospital general practitioner complaining that her left foot has been weak and numb for nearly three weeks and that the foot is difficult to flex. She denies any other weakness or numbness at this time. However, she reports that she has been very thirsty lately and gets up more often at night to urinate. She has attributed these symptoms to the extremely warm weather and drinking more water to keep hydrated. She has gained a total of 65 pounds since her last pregnancy 14 years ago, 15 pounds in the last 6 months alone. 

PMHx

• Seasonal allergic rhinitis (since her early 20s)
• Breast biopsy positive for fibroadenoma at age 30
• Gestational diabetes with fourth child 14 years ago
• Morning sickness with all four pregnancies
• HTN x 10 years
• Moderate-to-severe osteoarthritis involving hands and knees x 4 years
• Multiple yeast infections during the past 3 years that she has self-treated with OTC antifungal creams and salt baths
• Occasional constipation

PSHx

• C-section 14 years ago

OB-GYN Hx

• Menarche at age 12
• Menopause, natural, at age 46½; despite problematic hot flashes, she has chosen not to initiate HRT
• First child at age 17, last child at age 34, G4P4A0, all babies were healthy, 4^th child weighed 10lbs 6½ oz at birth
• Last Pap smear 4 years ago

FHx

• Type 2 DM present in younger sister and maternal grandmother; both were diagnosed in their late 40s; maternal grandmother died from kidney failure while waiting for a kidney 
• Father had emphysema
• Two older siblings are alive and apparently well
• All four children are healthy

SHx

• Married 29 years with 4 children; husband is a migrant farm worker
• Family of 5 lives in a 2-bedroom trailer
• Patient works full-time as a seamstress in a small =, family-owned business
• Smokers 2 ppd(since age 14) and drinks 2 beers most evenings
• Has “never used illegal drugs of any kind”
• Rarely exercises and admits to trying various fad diets for weight loss but with little success; has given up trying to lose weight and now eats a diet rich in fats and refined sugars

ROS

• Feel tired recently
• Has awakened on several occasions with blurred vision and dizziness or lightheadedness upon standing; denies vertigo, head trauma, ear pain, ringing sensation in the ears, difficulty swallowing, and pain with swallowing
• Denies chest pain, palpitations, and difficulty breathing while lying down
• Denies cough, shortness of breath, and wheezing
• Denies nausea, vomiting, abdominal bloating or pain, diarrhea, or food intolerance, but admits to occasional episodes of constipation
• Has experienced increased frequency and volumes of urination, but denies pain during urination, blood in urine, or urinary incontinence
• Denies leg cramps or swelling in the ankles and feet; has never experienced weakness, tingling, or numbness in arms or legs prior to this episode
• Menses stopped 2 years ago; is not sexually active but denies sexual dysfunction; also denies any vaginal discharge, pain or itching
• Has never had a seizure and denies recent headaches
• No history of chronic rash or excessive sweating
• Denies a history of goiter and has not experienced heat or cold intolerance

Meds

• Lisinopril 20mg po QD
• Acetaminophen 500mg with hydrocodone bitartrate 5mg 1 tablet po Q HS and Q 4h PRN
• Naproxen 500mg po BID (for mild-to-moderate osteoarthritis x 3½ years)
• Omeprazole 20mg po QD
• Docusate sodium 100mg po TID
• Loratadine 10mg po QD PRN

Allergies

• Sulfa drugs🡪 confusion

Physical Examination 

Vital signs: BP: 165/100mmHg    P: 88/min,     RR: 15/min,   BT: 98.0F,    HT: 5’3”,     WT: 203lbs,  

General: Significantly overweight Native American woman who appears slightly nervous, The patient is alert, oriented, and uses appropriate words, She does not appear to be acutely distressed and looks her stated age

Skin

• Dry and cool with tenting/poor skin turgor
• Significant xerosis on both feet with cracking
• Erythematous scaling rah in the axilla bilaterally
• (-) petechiae, ecchymoses, moles, or tumors upon careful inspection
• Normal capillary refill throughout

HEENT

• PERRLA, EOMs are intact
• R & L funduscopic exams showed mild arteriolar narrowing but without hemorrhages, exudates, or papilledema
• Sclera without icterus
• TMs intact and clear throughout with no drainage
• Mucous membranes dry

Nek: Supple, no masses, JVD, lymphadenopathy, or thyromegaly, (+) bruit auscultated over right carotid artery

Chest and Lungs: CTA, no crackles or rales noted

Cardiac: RRR with no murmurs, rubs, or gallops, Normal S1 &S2, No S3 &S4

Abdomen

• Soft abdomen
• NT with prominent central obesity
• (+) BS in all four quadrants
• (-) organomegaly, distension, or masses
• Faint abdominal bruit auscultated

Rectal/Genitalia: (-) vaginal discharge, erythema, and lesions, Hemorrhoids, stool guaiac-negative

MS/Ext: 

• Normal ROM in upper extremities
• Reduced ROM in knees
• (-) edema or clubbing
• Peripheral pulses diminished to 1+ in both feet
• Feet are cold to touch and dry with cracking, but no ulceration observed
• Strength 5/5 throughout except 2/5 in the left foot

Neurological

• A & O x 3, CNs II-XII intact, DTRs 2+
• Sensory response to light touch, proprioception, and vibration subnormal in both feet with abnormalities greater in the left foot
• Gait normal except for left foot weakness

Laboratory Blood Test and Urinalysis Results 

Questions

1. What is the significance of this patient’s cold feet and diminished peripheral pulses in the lower extremities?

2. Clinical signs are objective manifestations of a disease that can be identified by someone other than the patient. List a minimum of six signs from the case study above that support a diagnosis of type 2 diabetes in this patient.

3. List a minimum of five risk factors that predispose this patient to type 2 diabetes mellitus.

4. Which single urinalysis test result is more suggestive of type 2 than type 1 diabetes?

5. Which three blood chemistry test results strongly support a diagnosis of diabetes?

6. Why do stress and infection promote hyperglycemia in patient with diabetes?

7. Why should medications other than glipizide or glyburide be considered for management of diabetes in this patient?