History and Physical — Patient 77

History

Present Illness: This patient is a 62 year-old, right-handed Caucasian male who, despite osteoarthritis and chronic lower back problems, had been working up to 60 hours per week in heavy construction. His health began to deteriorate three months prior to his evaluation at the M.E. Debakey Veterans Affairs Medical Center (VA), beginning with the abrupt onset of a severe, stinging, burning pain in both feet that awakened him from sleep. By his description, the pain involved the entirety of both feet to the area just above both ankles. He reported the pain to be more intense in the left foot. He also reported chronic numbness on the lateral aspect of the left foot and across the toes in his left foot since sustaining a sciatic nerve injury as a complication of back surgery approximately ten years ago. The present pain, however, was unlike any he had ever experienced. He stated that movement of either the toes or the ankles exacerbated the pain. Covering his feet at night also elicited pain. Over the three months since onset, the pain in his feet had remained constant and unremitting. In addition to foot pain, the patient also noted significant shoulder, knee, and groin pain, which he ascribed to his long-standing osteoarthritis.

The patient was evaluated at the VA by the Podiatry Service for these symptoms, approximately six weeks before his hospitalization. Nerve conduction studies and electromyography, performed by the Physical Medicine and Rehabilitation service, suggested an axonal peripheral neuropathy. Gabapentin, piroxicam, and acetaminophen with oxycodone were prescribed for his pain, in close contact with his treating physicians, without significant relief.

The patient went to the VA emergency room after experiencing five days of nausea and vomiting. A physician at another health facility had prescribed promethazine, with only minimal symptomatic relief. The patient was unable to tolerate ingestion of either liquids or solids. He reported that he had been vomiting approximately once per hour. He reported no changes in his bowel habits and no abdominal pain. However, his lower-extremity pain continued unabated.

He was admitted to the hospital. The Neurology Service was consulted for further evaluation.

Past Medical History: Osteoarthritis and chronic low back pain. He denied diabetes mellitus, hypertension, thyroid disease, and symptoms of heart disease.

Past Surgical History: 1. Low back surgery for disc herniation approximately 10 years ago. 2. Arthroscopic surgery on the left knee.

Allergies: No known drug allergies.

Medications: Piroxicam 20 mg daily, oxycodone/acetaminophen 5/325 mg every 4 hours as needed for pain.

Social History: The patient reported smoking one pack of cigarettes a day for 30-35 years, until 1 week prior to admission. The patient drank socially and denied excessive alcohol consumption. He denied taking illicit drugs. He denied exposure to environmental toxins. He had been working as an ironworker for over 30 years, which mostly involved building metal frames of buildings.

Family History: His father died of cardiac illness. His mother is alive and in good health. One sister has breast cancer. He denied any family history of neuromuscular diseases.

Review of Systems: The review of systems was remarkable for a 20 pound weight loss over the several weeks prior to admission. He attributed this weight loss to anorexia as well as denture problems. The patient also reported chronic constipation, and a chronic cough productive of yellow sputum. He also reported dysuria, difficulty initiating a stream of urine, and difficulty maintaining a stream of urine. He denied experiencing dysarthria or dysphagia, chest pain, shortness of breath, skin rash, swollen lymph nodes, or joint swelling.

Physical Exam

General: Thin male appearing his stated age, keeping his eyes closed and obviously uncomfortable from nausea.

Vital Signs: Blood pressure 124/70 mmHg, pulse 70/min., respiration rate 20/min., temperature 97.0 F.

HEENT: Anicteric sclerae; moist mucus membranes.

Neck: No cervical lymphadenopathy; no carotid bruits on auscultation; no observable jugular venous distention.

Chest: Clear to auscultation in all lung fields.

Cardiovascular: Regular rate and rhythm; no murmurs, rubs, or gallops.

Abdomen: Normally active bowel sounds; soft, non-tender, non-distended abdomen; no masses palpable; no hepatosplenomegaly.

Spine: No costovertebral angle tenderness; no sacral edema.

Extremities: Good peripheral pulses and capillary refill in all four extremities. No lower extremity edema. A small nodule was noted on the posterior aspect of the left forearm near the elbow. No skin rash.

Neurological Examination

Mental Status: The patient's score on the Folstein Mini-Mental Status Examination was 28 of 30 points. He missed one point for the date and one point for 5 minute delayed recall.

Speech: Speech was fluent and without dysarthria. Language comprehension was intact.

Cranial Nerves: Cranial nerve examination was normal with the exception of diminished hearing to finger rub bilaterally.

Motor: Upper extremity strength was 5/5 except for 4+/5 at the deltoids bilaterally. Lower extremity strength was 5/5 except for 4+/5 strength of knee flexors. Tone was decreased throughout. There was normal muscle bulk.

Reflexes: 1+ at biceps bilaterally. Absent elsewhere.

Sensation: Proprioception, vibratory sensation, pin prick and temperature sensations were all diminished below the ankles and wrists, with lower extremities affected much more than upper extremities.

Coordination: Mild action tremor noted on finger-to-nose maneuvers on the left, with slightly decreased rhythm on rapid alternating movements of the left arm.

Gait: The patient was unable to place any pressure on the soles of his feet due to severe pain on contact with the floor.

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