Q: 58 year old male with a past medical history (PMH) of hypertension (HTN), Diabetes Mellitus (DM), Chronic Kidney Disease (CKD)-3 and coronary artery disease (CAD) with previous stents is admitted to ICU with chest pain. EKG seems unchanged from previous. First two troponins are negative. The patient described his chest pain different from previous as more sharp and burning. On examination, the patient found to have abdominal wall herniation. The patient will probably respond best to?
A) Nitroglycerine infusion
B) IV morphine
D) Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
E) Physical Therapy
Patient has diabetic thoracic radiculopathy, which can be very confusing in patients with poorly controlled diabetes and other underlying diseases. Chest pain is usually described differently as severe, sharp, and/or burning type. Many patients may develop abdominal muscle weakness and herniation. Fortunately, it is easy to treat and respond very well to gabapentin (dose up to 1200 mg three times daily). Non-responders may respond to 100 mg daily dose of nortriptyline or a course of 60 mg daily (divided) dose of oral prednisone.
Choice D is contra-indicated in this patient with underlying kidney disease. Physical therapy may help but it is not the first line of treatment. Nitroglycerine and morphine are not required as this is not the chest pain of cardiac origin.
Sun SF, Streib EW. Diabetic thoracoabdominal neuropathy: clinical and electrodiagnostic features. Ann Neurol 1981; 9:75. Chaudhuri KR, Wren DR, Werring D, Watkins PJ. Unilateral abdominal muscle herniation with pain: a distinctive variant of diabetic radiculopathy. Diabet Med 1997; 14:803.