The patient is a 75-year-old male attorney, who presents with a history of pain in both feet since 2008. He was diagnosed with diabetes mellitus type 10 years ago. He is already on oral hypoglycemics. The pain in his feet has been worsening over the time to the point that it is interfering with his enjoyment of life and activities of daily living. Other than that, over-the-counter medication and the use of Paxil, he has not used any other treatment to control his peripheral neuropathy. He describes his pain as follows: Triggering events: Diabetes mellitus. Duration: Constant. Quality and intensity: 10/10. Radiation/distribution: Pain starts in the ankle down to the foot. Aggravating factors: Walking and standing on his feet. Alleviating factor: Being off the feet and elevating the legs. Associated factor: Burning, numbness, sharp, aching and tingling pain.
1. Diabetes mellitus.
2. Lower extremity peripheral neuropathy.
1. I discussed with the patient the treatment options regarding the peripheral neuropathy. The treatments range from the use of medications in the form of pills as well as creams to the performance of through a spinal cord stimulator. We went over the risks, benefits, alternative and technical aspects of each option.
2. We will start the patient on Neurontin 300 mg one tablet p.o. q.h.s. I discussed with them the risks and benefit of this medication and the fact that it may cause some swelling. He denies any history of renal failure but we will consult with the primary doctor regarding his creatinine function and kidney function.
3. The patient will be enrolled in the peripheral neuropathy protocol.
4. EMG to document degree of peripheral neuropathy.
5. Follow-up in two weeks to reevaluate the use and progress with the medication.