Diabetic Neuropathy: Painless to Painful

Chris Pasero, MS, RN-BC

Disclosures

March 20, 2012

Case Presentation: A Woman With Painful Diabetic Neuropathy

The patient is a 42-year-old woman who has had type 1 diabetes since adolescence. Although she did not adhere to the prescribed diabetic treatment plan for several years, she has maintained good control of her diabetes with diet and insulin for the past 2 years. Her endocrinologist referred her to a neurologist 3 years ago when she reported "tingling" in her toes. The neurologic examination, which included nerve conduction studies, yielded the diagnosis of painless peripheral neuropathy of her toes and feet. At this routine visit with her endocrinologist, she reports that the neuropathy has now become painful and is interfering with her functional and quality-of-life goals.

History and Physical Examination

History. The endocrinologist obtains the following information about the pain from the patient:

  • She describes pain in the soles and all toes of both feet that feels "numb" and "like pins and needles." She also reports feeling occasional painful "sparks" in her toes.

  • The pain is continuous; the patient describes it being present most hours of every day and worse at night. She sometimes has difficulty going to sleep, and the pain often awakens her; she states that she often dreams about the pain before it awakens her.

  • Wearing socks and shoes is sometimes painful and causes her feet to feel "hot." To reduce the pain while she sleeps, she uses a bed cradle that raises the sheets off her legs.

  • The patient rates her average daily pain intensity as 5 and the worst pain as 7 on the 0-to-10 numeric rating scale.

  • Although she has continued to work 12-hour shifts as a registered nurse, the patient states that she is often distracted by the pain during work hours and is usually too tired to prepare meals or do housework after her shift is over and on her days off. She is concerned because she has been unable to maintain the exercise routine that she has followed for 2 years (walking 2 miles almost every day).

  • She has tried nonpharmacologic approaches to control the pain, including application of warm and cold packs, leg and foot massage, and elevating her feet above the waist. These have been unsuccessful in reducing the pain, although massage helps her relax.

  • Pharmacologic attempts to control the pain with around-the-clock naproxen and ibuprofen have been essentially unsuccessful. Despite poor results, she is currently taking 400 mg of ibuprofen every 6 hours and 1200 mg at bedtime. It is not uncommon for her to take 800 mg of ibuprofen every 6 hours while at work, even though the reduction in pain is minimal with this analgesic.

  • Her goal is to be able to work and exercise at a level similar to what she was able to do before the neuropathy became painful.

Physical examination. Physical examination reveals the following:

  • General appearance: The patient appears thin, sad, and tired; dark shadows are noted below her eyes; her posture is slumped.

  • Height, 5' 5"; weight, 114 lb (a decrease of 6 lb since her last visit 6 months ago).

  • Oral temperature: 98.2 oF.

  • Pulse: 74 beats/min.

  • Respiratory status: bilateral breath sounds are equal and clear; the respiratory rate is 20 breaths/min. The patient does not smoke.

  • Skin is warm; the nail beds and general skin color, including toes and feet, are pink.

  • Blood pressure: 128/78 mm Hg.

  • Neurologic: increased loss of sensation in the soles of both feet and all toes by means of pinprick and cotton wool testing since last visit 6 months ago.

Pertinent Laboratory Tests

  • Triglyceride level: 142 mg/dL

  • Cholesterol levels: total, 185 mg/dL; high-density lipoprotein, 61 mg/dL; low-density lipoprotein, 110 mg/dL

  • Complete blood count: within normal limits

  • Fasting blood glucose level: 82 mg/dL

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