Presenting Complaints

• The patient reports experiencing tingling and numbness in his feet and lower legs for the past 2-3 months.

History of Presenting Complaint

• The patient states the tingling and numbness began gradually and has been slowly worsening over time.
• The symptoms are worse at night and interfere with his sleep.
• He denies any recent injuries or trauma to his legs or feet.
• The patient reports feeling unsteady on his feet at times and has had a few near-falls, but no actual falls.
• He has not experienced any weakness or muscle wasting in his legs.

Significant Positives & Negatives For Differentials

Diabetic Peripheral Neuropathy

Positives:

• Long-standing type 2 diabetes diagnosis
• Gradual onset of symmetric lower extremity sensory symptoms (tingling, numbness)
• Worsening of symptoms at night
• Near-falls but no actual falls

Negatives:

• No history of significant weight loss or fatigue
• No bowel or bladder dysfunction

Vitamin B12 Deficiency Neuropathy

Positives:

• Symmetric lower extremity sensory symptoms
• Potential risk factor of long-term metformin use

Negatives:

• No history of anemia, macrocytosis, or other signs of B12 deficiency
• No history of malabsorptive conditions (e.g. pernicious anemia, gastrectomy)

Chemotherapy-Induced Neuropathy

Positives:

• Symmetric lower extremity sensory symptoms

Negatives:

• No history of cancer or chemotherapy treatment

Idiopathic Peripheral Neuropathy

Positives:

• Symmetric lower extremity sensory symptoms
• Absence of clear underlying cause

Negatives:

• Presence of type 2 diabetes as a potential etiology

Guillain-Barré Syndrome

Positives:

• Symmetric lower extremity sensory symptoms

Negatives:

• Gradual, symmetric presentation rather than acute, ascending paralysis
• Lack of other neurological deficits (e.g. weakness, areflexia)

Past Medical History

• Type 2 diabetes, diagnosed 10 years ago
• Hypertension, well-controlled on medication
• Hyperlipidemia, treated with a statin

Drug/Medication History

• Metformin 1000 mg twice daily
• Lisinopril 10 mg daily
• Atorvastatin 20 mg daily

Social History

• Retired, previously worked as an accountant
• Lives alone, independent with activities of daily living
• No history of alcohol or tobacco use

Family History

• No family history of neurological disorders
• Father had type 2 diabetes

Systems Review

• Denies any changes in vision, hearing, or speech
• No bowel or bladder dysfunction
• No unexplained weight loss or fatigue

Ideas, Concerns & Expectations

• The patient is concerned that the tingling and numbness may be a sign of a more serious neurological condition. He is hoping for a clear diagnosis and treatment plan to manage his symptoms.

Case Presentation

Based on the patient's history, physical exam findings, and the comprehensive review of the differential diagnoses, the most likely diagnosis is diabetic peripheral neuropathy. The key supporting features include the patient's long-standing type 2 diabetes, gradual onset of symmetric lower extremity sensory symptoms, and lack of other neurological deficits. While other potential causes were considered, the clinical presentation is most consistent with diabetic neuropathy.