Case27

Back ground

Linda G. is a 68-year-old university mathematics professor. She is married with 2 grown children and 4 grandchildren.
Linda was diagnosed with type 2 diabetes mellitus (DM) at the age of 44.
Her blood glucose is usually well controlled by oral antidiabetic agents and diet. At this visit, her blood glucose is normal and her logs indicate good glycemic control throughout the day and pre-and postmeal.
She was diagnosed with hypertension at the age of 55, for which she takes amlodipine besylate 5 mg once daily.
Patient's height: 5'8"; weight: 165 lb.
Blood pressure: 130/91 mm Hg.
Lungs: clear.
Blood glucose: 109 mg/dL.

About a year ago, Linda began to feel numbness in her feet, which gradually worsened, becoming uncomfortable and ascending to involve the distal leg; the discomfort gradually transitioned to pain.
She had been relatively active, walking about a mile to work every day and biking frequently during warm weather. She has recently begun using a cane to help her walk.
Over the last 2 weeks, the pain has gotten progressively worse; it is now intense and burning, and is accompanied by tingling and prickling sensations. Constant for most of the day, the pain is more intense at night and disturbs her sleep.
Her pain has caused her to miss work, and she is wondering if she should take a leave of absence.
She is also worried about weight gain because she is not as active as she used to be.
Linda also states that her discomfort has affected her enjoyment of family and social activities. She no longer participates in university social functions or activities with her family. She has canceled her vacation plans for next month.
On preliminary physical examination, Linda does not appear to have any pustules or rash, nor does she report any outbreaks in recent months.
Examination of her feet reveals a symmetrical pattern of foot pain that is not increased by stimulus.

The most probable cause of pain is Diabetic peripheral neuropathy.

Case 26

Background

A 64-year-old white male presented with 2 months of soreness of the muscles across his shoulders, lower back, and hips. The patient was also experiencing generalized fatigue and "heaviness" of the forearms after working. The sensation of heaviness in the forearms would start after he used his hands to do his usual daily activities and resolved after resting his forearms for a few minutes.
The patient did not have any complaints of Raynaud's phenomenon, joint pain, chest pain, abdominal pain, bitemporal headaches, jaw claudication, changes in his vision, or claudication of his lower extremities.
His past medical history was unremarkable. He had discontinued smoking 4 years earlier. There was no history of hyperlipidemia.
On physical examination, the patient was afebrile, but blood pressure could not be obtained in either arm. Upper-extremity pulses were absent bilaterally. No bruits were audible in the carotid or axillary areas and there were no digital ulcers. Cardiac examination was normal with no murmurs audible. Pulses in the lower extremities were normal. Bilaterally, temporal arteries were neither enlarged nor tender. There was no scalp tenderness. The joint examination was normal with no joint tenderness or synovitis. No other abnormalities were noted. A work-up was initiated.
On the basis of the patient's presentation, the differential diagnosis at this point would include which of the following?

The correct answer is 'E' All of the above.