A 48 year old male with a history of diabetes mellitus type 2 complains of not being able to feel his toes in the left foot. He also complains of numbness in the heel of the right foot and a tingling sensation. For this assignment you will create a focused/episodic note on your assigned case study. Then provide at least 5 differential diagnoses with rationales for each diagnosis. Include atleast 5 APA references Please use the attached template for the assignment

Case Study: Peripheral Neuropathy in a Patient with Diabetes Mellitus Type 2

Patient Information:
Name: Mr. Johnson
Age: 48
Gender: Male
Medical History: Diabetes Mellitus Type 2

Presenting Complaint:
Mr. Johnson presents with a complaint of not being able to feel his toes in the left foot. Additionally, he complains of numbness in the heel of the right foot and a tingling sensation.

Focused/Episodic Note:

Subjective:
Mr. Johnson reports a gradual onset of symptoms, which have been present for approximately six months. He describes the loss of sensation in his toes on his left foot as a complete absence of feeling. He expresses concern about potential complications, particularly foot ulcers, as a result of his inability to detect injuries. He also states that the numbness and tingling in the heel of his right foot are bothersome, but not as severe as the symptoms in his left foot. Mr. Johnson further reports having difficulty managing his blood glucose levels recently, as reflected in his last HbA1c result of 9.5%.

Objective:
On examination, the patient’s vital signs are within normal ranges. His neurological examination reveals diminished sensation to light touch and pinprick in the left toes. Reflexes are intact bilaterally, and muscle strength is normal. There are no visible signs of foot or leg deformities, ulcerations, or infections. The capillary refill time is less than 2 seconds. The patient has a monofilament score of 5/10 in the left foot and 8/10 in the right foot.

Assessment/Differential Diagnoses:

1. Diabetic Peripheral Neuropathy:
Mr. Johnson’s history of diabetes mellitus type 2 and characteristic symptoms of numbness, tingling, and loss of sensation in his feet strongly suggest diabetic peripheral neuropathy. This condition is a common complication of diabetes, which results from progressive nerve damage due to chronic hyperglycemia. Peripheral neuropathy typically affects the longest nerves first, starting in the feet and gradually progressing upwards. The gradual onset of symptoms, bilateral involvement, and HbA1c level of 9.5% support this diagnosis. Examination findings, such as diminished sensation and abnormal monofilament scores, further strengthen the likelihood of diabetic peripheral neuropathy.

2. Lumbar Radiculopathy:
Lumbar radiculopathy, also known as sciatica, is caused by compression or irritation of the nerve roots exiting the lumbar spine. Symptoms typically include pain, numbness, or tingling radiating down the affected leg. Although Mr. Johnson does not report significant pain, his complaint of numbness in the heel of the right foot could be consistent with lumbar radiculopathy. It is essential to consider this diagnosis as it may coexist with or mimic peripheral neuropathy in patients with diabetes.

3. Tarsal Tunnel Syndrome:
Tarsal tunnel syndrome is a compression neuropathy of the posterior tibial nerve within the tarsal tunnel. This syndrome presents similarly to peripheral neuropathy, with symptoms of tingling, numbness, and burning pain in the foot. However, it typically affects specific areas, such as the medial heel and sole, which matches Mr. Johnson’s description. Tarsal tunnel syndrome is more common in patients with diabetes due to the increased susceptibility of peripheral nerves to compression in the presence of neuropathy.

4. Alcoholic Peripheral Neuropathy:
Alcoholism is a known risk factor for peripheral neuropathy. Chronic alcohol abuse can result in nutritional deficiencies, including vitamin B12 deficiency, which can contribute to neuropathy. While Mr. Johnson’s history does not include alcohol abuse, it is necessary to consider this differential diagnosis to ensure comprehensive evaluation and exclude any potential confounding factors.

5. Charcot-Marie-Tooth Disease:
Charcot-Marie-Tooth disease (CMT) is a hereditary neuropathy characterized by progressive muscle weakness, atrophy, and sensory loss, primarily in the lower limbs. Although Mr. Johnson does not present with the typical signs of CMT, such as characteristic foot deformities, the possibility of this hereditary neuropathy should be considered due to the bilateral nature of his symptoms. A thorough family history and further genetic testing may be needed to confirm or exclude this diagnosis.

References:
1. American Diabetes Association. (2019). 11. Microvascular complications and foot care: Standards of medical care in diabetes-2019. Diabetes care, 42(Supplement 1), S124-S138.
2. Dyck, P. J., Thomas, P. K., & Griffin, J. W. (2005). Peripheral neuropathy. New England Journal of Medicine, 352(13), 1312-1324.
3. Hanewinckel, R., van Oijen, M., Ikram, M. A., & van Doorn, P. A. (2016). The epidemiology and risk factors of chronic polyneuropathy. European Journal of Epidemiology, 31(1), 5-20.
4. Rose, K. J. (2008). Common peripheral nerve disorders. Continuum: Lifelong Learning in Neurology, 14(1), 18-48.
5. Stewart, J. D. (2008). Footdrop: where, why and what to do?. Practical neurology, 8(3), 158-169.