We are excited to see so many of you join our FMEP courses. Several of you have requested we continue to post more practice SAMPs, so here you go!

SAMP

Jonathan Forest is a 62-year-old man with a 15-year history of type 2 diabetes who presents to your family practice complaining of burning pain in both feet. The pain is significantly worse at night, and it is now affecting his sleep. He also reports numbness and a “pins and needles” sensation. His HA1c last month was 8.4%. Medications: Metformin 1g PO BID, Lipitor 40 mg PO OD., and Perindopril 8 mg PO OD. He has a history of hypertension and gout. On examination, he appears well. BP is 127/72, HR 86. He has reduced sensation to monofilament testing at the plantar surface of both feet. He has reduced vibration sense at the great toe. There are no visible ulcers. (9 points)

1. List two screening and monitoring strategies for diabetic peripheral neuropathy. (2 points)

   Answer:
   Annual foot exam starting at diagnosis of type 2 diabetes
   Use of 10-g monofilament testing
   Use of a 128-Hz tuning fork for vibration sense
   Temperature sensation testing
   Reflex assessment (e.g., ankle reflexes)
   Distal-to-proximal examination
   Annual reassessment of the level of sensory loss

2. List three pharmacologic treatment options for this patient’s neuropathic pain. (3 points)

   Answer:
   Gabapentin
   Pregabalin
   Duloxetine
   Amitriptyline
   Topical capsaicin cream
   (Not appropriate: opioids as routine therapy)

3. List two counselling points appropriate to this condition. (2 points)

   Answer:
   Daily self-inspection of feet, skin, and nails
   Importance of glycemic control in slowing progression
   Risk of unnoticed injuries due to sensory loss
   Need to report new wounds promptly
   Use of proper footwear to prevent injury

4. A 70-year-old patient with diabetic neuropathy and significant daytime sedation is starting pharmacotherapy. Which of the following is the best initial approach? (1 point)
   1. Start high-dose gabapentin
   2. Start low-dose gabapentin and titrate slowly
   3. Start opioid therapy
   4. Avoid pharmacologic treatment
   5. Start combination therapy immediately

   Answer: B

5. Which of the following statements about topical capsaicin is most accurate? (1 point)
   1. It is first-line monotherapy for all patients
   2. It has no side effects
   3. It can provide pain relief, but it commonly causes local irritation
   4. It is more effective than all oral agents
   5. It is contraindicated in neuropathic pain

   Answer: C

Helpful CMAJ Resource:
https://www.cmaj.ca/content/198/16/E626