Bilateral lower extremity diabetic peripheral neuropathy.

The patient is a very pleasant 6 feet 1 inch, 320-pound insulin-dependent diabetic with bilateral lower extremity pain from the knees distally. He describes this as a numbness and tingling sensation, which is present even at rest. He states that the discomfort started in his feet approximately 15 years ago and he was diagnosed with diabetes approximately 20 years ago. He is extremely poorly controlled with his diabetes by history including double digit hemoglobin A1c values in addition to being 80 pounds greater in body weight. He states that he was using pregabalin for years, but this did not help and now he is on gabapentin. He uses compression stockings for sleep in the evenings and remains on very high Coumadin dose at this time for prior cardiac stenting.

ASSESSMENT:
This is a 6 feet 1 inch, 320-pound insulin-dependent diabetic with bilateral lower extremities paresthesias distal to the knee consistent with diabetic peripheral neuropathy.

IMPRESSION:
1. Bilateral lower extremity paresthesia distal to the knee; most consistent with diabetic peripheral neuropathy.
2. Query lumbar spondylosis and lumbar radicular pain.
3. Insulin-dependent diabetes.
4. Chronic anticoagulation with high dose Coumadin secondary to cardiac stenting.
5. Significant deconditioning, but the patient has lost 80 pounds and has decreased his hemoglobin A1c levels into the single digits.

PLAN:
I spent almost an hour in direct consultation with the patient discussing his case. The unfortunate situation is that he is on chronic anticoagulation.

At this point, my recommendation would be for bilateral lower extremity EMG study with Dr. to assess degree of peripheral neuropathy versus possible radiculopathy. Future treatment options would include medication management plus or minus physical rehabilitation modalities, plus or minus peripheral nerve blocks with physical rehabilitation, plus or minus sympathetic nerve blocks, plus or minus peripheral stimulator (P-stim) versus dorsal column stimulator trial. He did state that his cardiologist is willing to take him of his Coumadin for things such as dental procedures, but I would like to assess the degree of neuropathy versus possible radiculopathy before moving forward with any types of treatment.

He was happy with the visit today and we will schedule him for his EMG with Dr. I will see him back in three weeks for follow-up.

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