(Updated with Answer) The Medical Challenge: George’s Unnerving Surprise

George is a 46 year old painter from Scranton, Pennsylvania. He is a jovial fellow well-liked by his peers. When not painting, he and his friends revel in the delicacies specific to Northeastern Pennsylvania such as pierogies and Old Forge White Pizza. In addition, George is a significant smoker. Since the age of 15, he has smoked approximately one pack per day.

Over the last few years, George began to develop bizarre sensations in his hands and feet. He thought nothing of these, though, and ascribed these problems to old age. More recently, however, he began to notice cuts and bruises on his hands and arms at the end of his workday. Such injuries were not out of the ordinary in his line of work but strangely George did not notice these injuries when they occurred. Moreover, they did not particularly hurt.

One day, George awakens from his characteristically intense slumbering and realizes his vision is blurry. Specifically, he is seeing double and cannot seem to fully open his right eye. He decides on this day that it is finally time to seek the attention of a physician.

The last time George saw a physician, he was 15 years old. As such, he visits the local emergency room. The nurse checks his vitals.

Height: 5’10

Weight: 225

Body mass index: 32.3

Heart Rate: 85

Blood Pressure: 155/95

His Physician, Dr. Jankowski, reviews these vital statistics and proceeds to examine George after first discussing his symptoms and past medical history. On exam, he notices that George’s right eye is deviated and fixed towards the right side of his eye socket. When he asks George to move his right eye, he cannot though his left eye moves properly. In addition, George reports seeing double except when he looks toward the right. When Dr. Jankowski shines a light in George’s eyes, both pupils appropriately become smaller.

The top figure indicates the appearance of George’s eyes when he enters the Emergency room. In the bottom figure, the physician elevates his right eyelid and asks George to look towards the left which he cannot do. (Photos courtesy of Canadian Family Physician-www.cfpc.ca)

Dr. Jankowski proceeds to check George’s heart, lungs, and abdomen and finds no problems. Further, George appears to have good strength in his arms and legs. However, when Dr. Jankowski pokes George with a safety pin, George is barely able to perceive the pin particularly in his hands, forearms, shins, and feet. Finally, when George removes his socks, Dr. Jankowski notices a chronic appearing wound on the bottom of his left big toe. George reports being unaware of the wound.

What’s going on? What should we do?

Check back on Monday for the answer.

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Dr. Jankowski immediately understands George’s affliction. First, upon looking at George’s vital statistics, Dr. Jankowski notices that George is both overweight and hypertensive(high blood pressure). Then he thinks about George’s story. George has had a few year history of strange sensations in his extremities. Furthermore, He has a chronic, non-healing wound on his foot. Finally, he has an acute problem with the movement of his right eye. These signs and symptoms point to problems with George’s nerves and given George’s age, lifestyle, weight, and blood pressure, Dr. Jankowski suspects George to have a severe diabetic neuropathy from complications of type II diabetes.

Diabetes Mellitus is a group of disorders characterized by high blood sugar that can ultimately lead to complications with the eyes, nerves, arteries, and kidneys of the human body(this is only a partial list). George’s specific diagnosis is that of type II Diabetes which is thought to affect nearly 25 million Americans. Moreover, at least $130 billion dollars in direct and indirect diabetes care costs are spent in the US every year. Sadly, the disease is the leading cause of blindness in adults, end stage renal disease(requiring either dialysis or kidney transplant), and non-trauma related limb amputations. The causes of this disease are heterogeneous and complex but put simply, genetics that predispose one to high blood sugar are mixed with a lifestyle that impedes the body’s ability to maintain proper sugar balance. Lifestyle factors of relevance in George’s case include his excessive caloric intake, poor exercise routine, obesity, and cigarette use.

Because George has had undiagnosed diabetes for likely quite some time, he has had damage to the nerves and arteries(and potentially other organs) in his body. Classic for diabetes, the nerves in the hands, forearms, feet and shins become diseased and essentially dysfunctional. This explains George’s strange sensations in his hands and feet, and his more recent symptoms of numbness in these areas. Moreover, because George cannot feel his feet adequately, he is unaware of the repetitive stress he suffers to his feet from everyday living. As a result, he has developed a chronic non-healing wound known as a diabetic foot ulcer. The wound has a difficult time healing because damage to his blood vessels from diabetes has severely limited blood flow to the injured area of his foot. Without blood flow, the body cannot heal the wound leading to the foot ulcer and potentially life threatening infections.

Similarly, George’s problematic right eye results from damage to the nerves controlling eye movements. There are three nerves that control movements of the eyes and the long standing nature of George’s diabetes has impaired the so-called Cranial Nerve III without which normal eye movements are impossible. In addition, that same nerves helps control the muscles that elevate the eyelid which if compromised results in a droopy eye like George’s.

George is therefore in trouble. He needs an aggressive change in his lifestyle consisting of exercise and diet control. He is significantly overweight as indicated by his Body Mass Index(to compute yours, go to http://www.nhlbisupport.com/bmi/ ). He needs to quit smoking which in addition to its attendant cancer risk also compounds the damage to blood vessels already caused by his diabetes. At this stage, he needs medicines to not only treat his high blood sugar but also control his high blood pressure. Finally, he needs to get a primary care physician to help him manage his diabetes as this will be a problem that requires lifetime care.

The good news is that George’s eye problems will likely resolve in 6-8 weeks. However, George’s numb, achy hands and feet may not get much better though pain in these areas can be well managed with certain medications. Improvement, though, is possible and George getting his blood sugar under rapid control optimizes his chances. With regards to his foot ulcer, nearly 15% of diabetics develop a foot ulcer and of these, perhaps 10-20 % may eventually require an amputation to prevent gangrenous complications. Treatments, thankfully, do exist for foot ulcers and include aggressive management of the diabetes, local wound care(using a variety of dressings and gels/creams), and antibiotics if necessary. Sometimes, surgery is required to debride the wound for optimization of wound healing.

The message here is that type II diabetes and its complications are largely problems that can be minimized, even avoided through a combination of lifestyle modifications and medical vigilance. In fact, cases of type II diabetes caught early can in some instances be cured by exercise and diet alone. Unfortunately, the complications George has suffered from his diabetes represent those of a more advanced stage and only a partial list of those possible. Finally, at this advanced stage of his diabetes, reversal of all his symptoms to his pre-diabetic state is generally not achievable. George must now learn to live with and manage his diabetes for the rest of his life.

As a society, we can do much to prevent diabetes through education and healthy lifestyle choices. For more information on educational materials, activism, dietary hints, and opportunities to support diabetes research, please visit the American Diabetes Association at www.diabetes.org

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