Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

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

mksap
Conditions
October 25, 2014
56 Shares
Share
Tweet
Share

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

MKSAP Answer and Critique

The correct answer is A. Desipramine.

This patient should be treated with desipramine. He is experiencing an acute episode of painful diabetic neuropathy that developed after a period of poor glycemic control. This disorder involves acute segmental demyelination in the peripheral sensory nerves. Remyelination and recovery can occur if excellent glycemic control (HbA1c level <7.0%) is established and maintained for several months. Relief of symptoms often is obtained by administering a low-dose tricyclic antidepressant, such as desipramine; topical application of capsaicin cream is also appropriate.

Fluoxetine and other selective serotonin reuptake inhibitors are ineffective for treating painful diabetic neuropathy and should not be used in this patient.

Nerve conduction studies might show marked slowing of nerve conduction, and a sural nerve biopsy would confirm the presence of segmental demyelination. These diagnostic tests, however, are unnecessary in a patient in whom the diagnosis of acute painful diabetic neuropathy is so likely, given his compatible history and physical examination findings.

Starting a potentially addictive and dangerous drug (such as oxycodone), especially when used for prolonged periods, is inappropriate therapy for a condition that may well be self-limiting.

Key Point

  • Symptoms of painful diabetic neuropathy can be treated with a low-dose tricyclic antidepressant and topical application of capsaicin cream.

This content is excerpted from MKSAP 16 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

Prev

Twitter counts for this doctor. Read why.

October 24, 2014 Kevin 2
…
Next

An Ebola parody that educates. Watch why it should go viral.

October 25, 2014 Kevin 16
…

Tagged as: Diabetes, Endocrinology, Neurology

Post navigation

< Previous Post
Twitter counts for this doctor. Read why.
Next Post >
An Ebola parody that educates. Watch why it should go viral.

More by mksap

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 26-year-old man with back pain

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 36-year-old man with abdominal cramping, diarrhea, malaise, and nausea

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 52-year-old woman with osteoarthritis of the right hip

    mksap

More in Conditions

  • Why patients write: stress relief, self-care, and sharing experiences

    R. Lynn Barnett
  • Misinformed claims and the offensiveness of discrediting COVID-19 vaccine development

    Angel Garcia Otano, MD
  • Family support is pivotal in the treatment of schizophrenia

    Frank Chen, MD
  • Exploring disfigurement and self-worth

    Kathleen Watt
  • Are we doing enough to help chronic pain sufferers?

    Adam Strohl, MD
  • Lessons taught by Bell’s palsy

    Alexander Rakowsky, MD
  • Most Popular

  • Past Week

    • I’m a doctor, and I almost died during childbirth

      Bayo Curry-Winchell, MD | Physician
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Motorcycle helmet laws: Balancing freedom and financial impact

      Stephen Cohn, MD | Conditions
    • Balancing efficiency and compassion [PODCAST]

      The Podcast by KevinMD | Podcast
    • The link between orofacial myofunctional disorders and dental health

      Stephanie Jeret | Conditions
    • How compassionate leadership saved this physician [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Navigating the broken medical system: challenges faced by foreign medical graduates

      Anonymous | Physician
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
    • The essence of medicine: genuine connections in practice

      Jennifer Tillman, MD | Physician
  • Recent Posts

    • Balancing efficiency and compassion [PODCAST]

      The Podcast by KevinMD | Podcast
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Why patients write: stress relief, self-care, and sharing experiences

      R. Lynn Barnett | Conditions
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • Misinformed claims and the offensiveness of discrediting COVID-19 vaccine development

      Angel Garcia Otano, MD | Conditions
    • Bitcoin’s role in diversified portfolios [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 1 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Did Gabapentin Improve Post-COVID Olfaction?
  • Fentanyl Death Trends; Food Additives and Heart Disease
  • What If the Doctor Is Out?
  • Reduced Mortality Seen in Cancer Survivors Who Meet Exercise Guidelines
  • CDC Advisors Endorse Maternal RSV Vax to Protect Newborns

Meeting Coverage

  • Loneliness Needs to Be Treated Like Any Other Health Condition, Researcher Suggests
  • Stopping Medical Misinformation Requires Early Detection
  • AI Has an Image Problem in Healthcare, Expert Says
  • Want Better Health Outcomes? Check Out What Other Countries Do
  • ERS Roundup: Cell Transplant Boosts Lung Function in COPD Patients
  • Most Popular

  • Past Week

    • I’m a doctor, and I almost died during childbirth

      Bayo Curry-Winchell, MD | Physician
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Motorcycle helmet laws: Balancing freedom and financial impact

      Stephen Cohn, MD | Conditions
    • Balancing efficiency and compassion [PODCAST]

      The Podcast by KevinMD | Podcast
    • The link between orofacial myofunctional disorders and dental health

      Stephanie Jeret | Conditions
    • How compassionate leadership saved this physician [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Navigating the broken medical system: challenges faced by foreign medical graduates

      Anonymous | Physician
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
    • The essence of medicine: genuine connections in practice

      Jennifer Tillman, MD | Physician
  • Recent Posts

    • Balancing efficiency and compassion [PODCAST]

      The Podcast by KevinMD | Podcast
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Why patients write: stress relief, self-care, and sharing experiences

      R. Lynn Barnett | Conditions
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • Misinformed claims and the offensiveness of discrediting COVID-19 vaccine development

      Angel Garcia Otano, MD | Conditions
    • Bitcoin’s role in diversified portfolios [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

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

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...