Question of the Week # 359

359)  A 50 year old woman with history of Diabetes Mellitus presents to your office with complaining of discomfort in her both legs for past few months. She describes unpleasant sensations as well as abnormal sensations such as including tingling, creeping and itching sensations deep in her legs while sitting. Walking a few steps relieves her symptoms. She denies any pain in the legs upon walking or at rest. Physical examination reveals slightly diminished pulses in bilateral lower extremities.  Which of the following is the first step in managing her symptoms?

A) Nerve Conduction Studies

B) Cilostozol

C) Dopamine Agonists

D) Obtain Serum ferritin

E) Gabapentin

11 Responses

  1. patient is sufring frm peripheral vascular disease. Cilastazol

    • Thanks for answering, mukesh but What are the symptoms of peripheral vascular disease and what makes you think peripheral vascular disease is causing her symptoms? Please check the question again. Some clues may be missed when you glance it once. The strategy to answer MCQ on your board exams accurately is to put the complete information in the question together and see what features fit and what do not. Often dis-tractors are present in the question like they always do in our real life when you are getting a history or doing a physical. Putting the information together and elimination methods in answering MCQs will help you score good on multiple choice questions.

  2. C) Dopamine Agonists – Restless leg syndrome – worsens on rest, relieved on moving
    Diabetic neuropathy – proprioception is lost first -can be easily diagnosed with tuning fork test…nerve conduction studies is not required. Also it is not relieved by moving or get worse on rest.
    PVD – Diminished pulses may point to it but the patient is asymtomatic – no claudication on walking.

    • Hi Shru; As always, you got the diagnosis correct and good reasoning. However, what is the first step in managing Restless Legs Syndrome?

      • No way! Is it D) Obtain Serum ferritin ?
        correct iron deficiency first?

      • Correct!

        Answer D. The patient has Restless Legs Syndrome. Restless legs syndrome is characterized by deep-seated dysesthesias (unpleasant sensations) and paresthesias ( abnormal sensations such as creeping, tingling, crawling and itching) . These sensations occur at rest and are relieved by activity (moving legs or walking). RLS may be associated with several secondary disorders such as Iron deficiency, Uremia and electrolyte imbalances. Most importantly, association between Iron deficiency and RLS has been strongly established and all patients with newly diagnosed RLS should be screened for iron deficiency using serum ferritin. Patients with iron deficiency report significant improvement in RLS upon repletion of their Iron stores.
        Option A is incorrect. Nerve conduction studies are appropriate if a diagnosis of peripheral neuropathy is suspected. Also, even in case of diabetic neuropathy, Nerve Conduction Studies are not required since diagnosis can be established by history, physical examination and by using tunic fork to assess vibration perception. However, this patient’s symptoms are not due to peripheral neuropathy. RLS may be confused with peripheral neuropathy. However, dysesthesias and paresthesias of peripheral neuropathy do not resolve upon walking or moving the extremities. Moreover, neuropathy may be associated with pain but pain is never a feature of RLS.
        Option B is incorrect. Cilostozol is a phosphor-diesterase inhibitor used in treatment of claudication pain secondary to peripheral vascular disease that does not improve despite supervised exercise therapy. The patient does not have claudication pain. She may have co-existing PAD secondary to her diabetes in view of diminished pulses however, this is not causing her symptoms at this time.
        Option C is incorrect. Dopamine agonists such as Ropinirole and Pramipexole are agentys of chooce in treating moderate to severe RLS. However, the first step in RLS is to investigate reversible causes such as iron deficiency and if present, to adequately treat them.
        Option E is incorrect. Gabapentin can be used in mild to moderate RLS and also, in peripheral neuropathy. However, the first step in RLS is to investigate reversible causes such as iron deficiency and if present, to adequately treat them.

  3. it is diabetic neuropathy so it should be gabapentin…that is E

  4. Truly amazing questions! thankyou so much!!

  5. ddddddddd

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