Illness Script for Type 1 Diabetes

Case Description:

A 65-year-old, Caucasian male is referred to physical therapy by his primary care

provider for balance issues from diabetic neuropathy (see O above). The patient reports
an insidious onset of pain over the last few months with increased infections in bilateral
LE’s. He did not notice that activity improves his pain nor that positioning impacts the
pain. He is recently retired, so his activity level has decreased. Noted that patient is
leery to do much activity, since his decrease in balance.

When screening for Red Flag signs and symptoms, you learn that he has had episodes
of where he loses his balance while standing. He reports that his balance has
decreased since his diagnosis and he expresses a lot of concern about injuries due to
falls. He has noted that his legs are susceptible to infection and has a history of
cuts/infections. Upon examination, you do not see any open skin lesions, but notice the
discoloration of his legs and dryness of his skin. The patient notes that this has been the
discoloration of his legs for quite some time, but he does not notice when he is bleeding
from wounds until there is enough blood that his wife points out. Nothing has improved
his legs conditions.

Past Medical History: Has been diagnosed with type 1 diabetes since the age of 12. No
significant history of surgeries, but the surgery for his insulin pump; no significant
musculoskeletal injuries besides some cuts and infections; no known allergies, and
current medication is an insulin pump.

Physical Features:

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You note a pleasant older man with a thin, tall build. He is not in any specific pain, but
has no feeling in his feet. You do notice that the patient has no sensation in bilateral LE,
discoloration of the legs, and dry flaky skin. He has no open wounds present at this
time.

Physical Therapy Findings:

Upon physical therapy examination, you note that the patient has very poor balance.
Patient has weak core and leg muscles. Upon sensory testing, there is a decrease
sensation of hot/cold and sharp/dull in the LE’s. Upon testing his muscle strength, you
note that the patient has extreme fatigue and often needs to rest upon exertion.

Problems List:

Extreme fatigue
Decrease strength in LEs
Decrease balance/stability
Decrease sensation in bilateral LEs

Differential Diagnosis (What is this similar to? What should be ruled

out?)

Diabetic neuropathy is similar to other types of neuropathy from AIDS, syphilis, and
kidney failure. The difference is that diabetic neuropathy is related to high blood sugar
levels as opposed to infection or impaired fluid circulation. This particular type of
neuropathy could be ruled out by taking glucose levels and comparing them with normal
ranges. If a decrease of balance is noticed, medical professionals should first rule out
that the patient does not have a peripheral nerve injury or a pinched nerve in the spinal
cord. Other neurological disorders should be ruled out by utilizing specific tests that
address their unique qualities. For Type 1 Diabetes Mellitus, a physical therapist should
check to make sure there is accurate blood flow to the LEs by taking a dorsalis pedis
pulse, as peripheral arterial disease (PAD) and peripheral neuropathy are common
occurrences for this disease.

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