Presenting Complaint:

• Progressive numbness and burning pain in both feet.
• “I’ve noticed my feet have felt numb for months now, but recently they’ve started burning badly, especially at night.”

Symptoms (SOCRATES):

• Site:  Distal lower limbs, particularly feet – “It’s mainly my feet that feel like they’re asleep or burning. Sometimes I also feel the burning pain and numbness in both my hands.”
• Onset: Gradual onset over 6 months – “It started slowly, just a bit of numbness, but now it’s worse.”
• Character: Burning and tingling sensation – “It feels like pins and needles mixed with burning.”
• Radiation: Proximal radiation – “The sensation started in my toes and now is spread throughout both my feet, but it doesn’t move up my legs. It is also now affecting my hands.”
• Associated symptoms: Numbness, occasional mild weakness in feet – “Sometimes I feel clumsy, like I might trip.”
• Time: Worse at night, persistent throughout the day – “It bothers me mostly when I’m trying to sleep.”
• Exacerbating factors: Rest and night-time – “It gets worse when I’m lying down.”
• Alleviating factors: Movement and walking – “Walking seems to help a little.”
• Severity: Moderate intensity (5/10) with intermittent severe episodes (8/10) – “Some nights the pain really wakes me up.”

Systemic Symptoms:

• Fatigue: None.
• Fever, night sweats, unintended weight loss: None.
• Chest pain: None.
• Dizziness: Yes – “Sometimes I feel funny and lightheaded when I stand up from sitting, I have not fallen over though or passed out.”
• Shortness of breath or cough: None.
• Oedema: None.
• Change in bowel habits: Yes – “I get constipated from time to time.”
• Urinary symptoms: Frequency, nocturia, hesitancy, weak stream – “I have to go quite often now, and sometimes over night a few times. It’s getting harder to get it started though, and it’s quite a weak stream with dribbling sometimes.”
• Erectile dysfunction: Yes – “I am quite embarrassed to admit this, but it’s been harder to have sex with my partner recently as I am having issues with maintaining an erection.”
• Abdominal pain: None.
• Nausea: Yes – “I feel quite nauseous and feel bloated especially after eating a big meal. I have not vomited as of yet.”
• Rashes or skin changes: None.
• Headache: None.
• Mood changes: Mild anxiety due to symptoms – “I do worry sometimes about what’s causing this.”
• Sleep disturbances: Yes, due to pain – “The burning keeps me awake.”
  

Past Medical History:

• Type 2 Diabetes Mellitus diagnosed 8 years ago.
• Hypertension diagnosed 5 years ago.
• No previous surgeries or hospitalisations.
• No previous major injuries.

Drug History:

• Metformin 1g twice daily. 
• Lisinopril 10mg once daily.
• No missed doses or non-compliance – “I’m good at taking my tablets.”
• No herbal supplements/alternative therapies.
  

Allergies:

• Penicillin allergy causing rash and itching – “If I take penicillin, I get a nasty rash.”

Family History:

• Father had type 2 diabetes and died of myocardial infarction aged 65.
• Mother alive, hypertensive but no diabetes.
• No family history of neurological diseases.
• No known genetic conditions.

Social History:

• Lifestyle: Sedentary office worker, spends most time sitting.
• Activities of Daily Living and Hobbies: Enjoys gardening and occasional walking in local parks.
• Smoking: Ex-smoker, quit 10 years ago, 15 pack-year history.
• Alcohol: Drinks socially, about 10 units per week.
• Recreational Drug Use: Denies any use.
• Diet: Traditional Mediterranean diet, rich in vegetables, fish, olive oil; also eats sweets regularly.
• Exercise: Walks 2-3 times per week for 30 minutes.
• Sexual history: Monogamous, only sexual partner is wife lifelong, no past STIs.
• Travel History: No recent international travel or exposure to unusual water or foods.
• Recent Exposure to Unusual Foods: No recent unusual meals or food poisoning episodes.
• Recent Life Events: No recent major life changes or stressors.

Ideas, Concerns, and Expectations:

Ideas:

• Believes symptoms may be related to “old age” or diabetes.
• “I think my diabetes might be causing this numbness.”

Concerns:

• Worried about losing sensation permanently or becoming disabled.
• Concerned symptoms might worsen and impact mobility.
• “I’m scared I might lose feeling in my feet completely.”

Expectations:

• Wants clear explanation and treatment plan.
• Hopes for pain relief and prevention of further damage.
• “I want to know what’s causing this and how it can be treated.”

Observations:

• Respirations (Breaths/min): 16 breaths/min
• Oxygen Saturation (%): 98% 
• Air or Oxygen: Air
• Blood Pressure (mmHg): 135/85 mmHg
• Pulse (Beats/min): 82 beats/min regular
• Consciousness (AVPU): Alert
• Temperature (Celsius): 36.7°C

NEWS: 0

• Weight: 107.2kg
• Height: 1.75m
• BMI: 35 

Physical Examination:

General Inspection:

• Gait: steady, coordinated, with normal stride and arm swing. No foot drop bilaterally. 
• No asymmetry, swelling or deformities.
• Scar on right foot between 2 toes.
• No erythema.
• No muscle wasting.
• No muscle spasms, fasciculations, or tremors.
• No hair loss or nail dystrophy.
• Ulcer on sole of right foot on metatarsal head – oval, well defined edges, callus formation around edges, patient reports no pain.
• No evidence of fungal infections.
• Normal foot arches and no joint deformity.
• No medical equipment or mobility aids present.

Palpation:

• Warm temperature in both feet 
• Present peripheral pulses: dorsalis pedis and posterior tibial palpable bilaterally 

Neurological Lower Limb Examination:

• Tone is normal in both lower limbs

• Power preserved proximally (MRC 5/5). Bilateral distal lower limb weakness of toe dorsiflexion (MRC 4/5)

• Reflexes: Ankle jerk absent bilaterally. Knee jerk present bilaterally. Plantar reflexes downgoing bilaterally

• Sensation:
  • Bilateral sensory loss present in a glove-and-stocking distribution
  • L5–S1 dermatomes show reduced light touch and pinprick sensation. More proximal dermatomes (L2–L4, S2–S3) are normal
  • Vibration sensation with a 128Hz tuning fork is decreased at the toes and ankles
  • Peripheral nerve sensation as below:

Examination of Specific Peripheral Nerves – Bilateral Upper Limb and Lower Limb 

Monofilament test:

• Base of big toe: Reduced sensation on bilateral feet  
• Metatarsal head (under toe 1, 3, 5): Decreased sensation bilaterally 
• Heel: Reduced sensation bilaterally

Proprioception:

• Big Toe: impaired proprioception bilaterally- patient unable to correctly identify up/down movement with eyes closed
• Ankle: intact proprioception bilaterally
• Knee: proprioception intact 

Blood Tests:

• Full Blood Count (FBC): Normal
  • Hb: 140 g/L (130-170)
  • WBC: 6.2 x10^9/L (4.0-11.0)
  • Platelets: 230 x10^9/L (150-400)
• Urea and Electrolytes: Evidence of CKD2 on today’s and previous blood tests
• Liver Function Tests: Normal
• CRP: 3 mg/L (<10)
• Haematinics: Normal B12 and folate levels
• Random Capillary Blood Glucose: 15 mmol/L
• HbA1c: 96 mmol/mol (48-57)
• Thyroid Function Tests: TSH 3.0 (0.4-4.0), T4 20.1 (9.0-25.0), T3 5.0 (3.5-7.8) 
• Lipid Profile: (mmol/L)
  • Total Cholesterol: 7.5 (<5.0)
  • LDL Cholesterol: 5.0 (<3.0)
  • HDL Cholesterol: 0.9 (>1.0)
  • Triglycerides: 3.0 (<1.7)
  • Total Cholesterol/HDL ratio: 8.3 (<4.0)

Urine Albumin-to-Creatinine Ratio: >3.5

Choose EITHER examiner viva questions OR patient communication questions

Patient Questions:

1. “Is this nerve pain going to get worse, and will I ever get better?”

• Possible answer: “The neuropathy often progresses slowly, however unless we control your blood sugar levels, it will keep getting worse and cover more of your arms and legs. You may also get painless ulcers and wounds on your feet, and eventually the bones in your feet may break and dislocate, causing deformity. Unfortunately it is very hard to reverse nerve damage, but with strict blood sugar control and treatment starting now, we can slow it down.”

2. “Are there any treatments to stop this nerve damage?”

• Possible answer: “Unfortunately nerve damage is often permanent, however controlling your diabetes strictly and managing symptoms is the best way that you can slow progression and improve your quality of life. We will arrange for regular foot care and inspection with our nursing team, and will monitor other organs such as your kidneys and eyes, which can also be affected by diabetes.”

3. “Could this lead to me losing my feet or needing amputation?”

• Possible answer: “With appropriate care and foot checks, we aim to prevent complications such as ulcers and even amputation. If your diabetes remains poorly controlled, however, you may develop more and larger ulcers, as well as serious deformity and fractures in your feet, termed ‘Charcot’ and ‘Rocker-bottom’ foot. Diabetes can also damage the blood vessels in your legs, causing poor blood supply, which can eventually result in tissue death. I’m sorry to say that this may require amputation if it continues to progress.”

4. “Will the burning pain ever completely go away?”

• Possible answer: “Pain control is possible but can be challenging; some patients find good relief with medication and lifestyle changes. Because nerve damage is often permanent, it is unlikely that the sensation will ever completely disappear.”

5. “Should I be worried about other parts of my body being affected?”

• Possible answer: “This neuropathy typically affects feet and legs first, and can continue to spread upwards to your upper legs and arms if not controlled. Diabetes can also damage your eyes, kidneys, as well as the nerves controlling your internal organs such as the gut, blood vessels and bladder – today you have described some symptoms which could well be related to this. This can lead to problems with feeling dizzy, problems eating and feeling bloated or full, constipation and difficulty urinating normally, in addition to erectile dysfunction.”

Examiner Questions:

1. What is the pathophysiology behind diabetic neuropathy?

• Possible answer: Chronic hyperglycaemia causes metabolic and microvascular damage leading to nerve ischaemia and demyelination. This typically affects distal peripheral nerves first, affecting sensation in a ‘glove-and-stocking’ distribution, and causing motor weakness in late stages. Autonomic neuropathy can also develop, leading to urinary and bowel symptoms, orthostatic hypotension, nausea, postprandial vomiting and early satiety from gastroparesis.

2. How do you differentiate diabetic neuropathy from other causes of peripheral neuropathy?

• Possible answer: In this case, there is a characteristic symmetrical stocking-glove distribution, with an associated longstanding history of poorly-controlled diabetes. Other causes can be excluded via blood tests, such as B12 deficiency and hypothyroidism.

3. What are the key components of the management plan for this patient?

• Possible answer: Strict optimisation of glycaemic control and diabetic risk factors, weight loss and exercise, symptom management, with neuropathic analgesics (e.g., duloxetine, gabapentin), foot care, and patient education. Monitoring other organ systems which are at risk e.g. renal and eyes, management of complications e.g. Charcot foot, autonomic neuropathy.

4. What are potential complications if diabetic neuropathy is left untreated?

• Possible answer: Foot ulcers, infections such as cellulitis, osteomyelitis or necrotising fasciitis, Charcot and Rocker-bottom foot, amputation, and decreased quality of life due to pain and disability.