Identifying Data:
Name: Mr. S
Sex: Male
Address: Lawrence, NY
Date of Birth: 4/10/1979, 42 years old
Date & Time: 10/21/21, 11:30 AM
Location: Southshore Family Medical, Arverne, NY
Marital Status: Married
Race: Indian
Source of Information: Self
Reliability: Reliable
Mode of Transport: Car
Chief Complaint: “my hands hurt” x 3 weeks
History of Present Illness:
42 y/o Indian male pt with Vitamin D deficiency presents to office ℅ pain in hands and feet x 3 weeks. Pt states he feels a constant aching pain in the joints of his fingers, which began gradually and has been worsening and spreading to his nails and in his feet, but is non-radiating. He states the pain is always present but is worse in the morning and night and better throughout the day, rating the severity between 4/10- 8/10. He states that the pain has gotten so bad that he can no longer pick things up or do regular activities, since is it too painful. Admits pain is aggravated by bending fingers and alleviated by opening the hands. States he used icyhot and biofreeze which provided very temporary relief, did not take any PO medications for the pain. Also admits to slight inflammation, parasthesias and weakness, but no numbness, in his hands and feet, as well as overall lethargy, fatigue, and weakness, which causes him to not want to get out of bed. Pt reports that he owns his own business and has not been working as much due to the fatigue. Denies fever, HA, dizziness, myalgias, arthralgias, numbness, decreased ROM, upper/lower extremity swelling, CP, SOB.
Past Medical History:
Present medical illnesses – Vitamin D deficiency
Past Illnesses- Pancreatitis (2015)
Childhood illnesses – none
Immunizations – Up to date
Screening Tests- none
Blood Transfusions- none
Past Surgical History: none
Hospitalizations: Pancreatitis, 2015
Medications:
none
Allergies:
No known food, drug, or environmental allergies.
Family History:
Mother –72, alive and well
Father – deceased at age 70, hypertension
Daughter-19- alive and well
Son- 18- alive and well
Daughter- 10, alive and well
Social History:
Mr. V is a 42 y/o married male. He works from home in a family-owned business. He lives at home with his wife and children.
Habits – Admits to heavy ETOH use on weekends. Drinks one cup of tea every morning and evening. Denies smoking, use of e-cigarettes or any illicit drug use.
Travel- Denies any recent travel.
Safety- Admits to wearing seat belt.
Sleep –States he sleeps well, for about 9 hours a night, but still feels constant tiredness and fatigue.
Exercise – States that he does not exercise regularly, especially recently due to the fatigue and pain.
Diet- Patients maintains a balanced diet.
Sexual History: Monogamous, admits to being currently sexually active with female partner. Denies history of sexually transmitted infections.
Review of Systems:
General – Admits to current generalized weakness and fatigue. Denies loss of appetite, recent weight loss or gain, fever, chills, or night sweats.
Skin, hair, nails –Admits to pain on his fingernails and toenails. Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.
Head – Denies dizziness, headaches, vertigo or head trauma, unconsciousness, head fracture or coma.
Eyes –Denies visual disturbances, fatigue, lacrimation, photophobia, and pruritus.
Ears –Denies ear pain, discharge, or use of hearing aids.
Nose/sinuses – Denies discharge, obstruction or epistaxis.
Mouth/throat – Denies sore throat, sore tongue, bleeding gums, mouth ulcers, voice changes.
Neck –Denies stiffness/ decreased ROM, localized swelling/lumps
Pulmonary system – Denies dyspnea, shortness of breath, cough, wheezing, orthopnea, paroxysmal nocturnal dyspnea, cyanosis or hemoptysis.
Cardiovascular system –Denies chest pain, palpitations, irregular heartbeat, syncope or known heart murmur.
Gastrointestinal system –Denies changes in appetite, intolerance to foods, abdominal pain, nausea, vomiting, diarrhea, constipation, flatulence, dysphagia, pyrosis, eructation, jaundice, hemorrhoids, rectal bleeding, or blood in stool.
Genitourinary system –Denies urinary frequency, urgency, polyuria, oliguria, nocturia, incontinence, dysuria, hesitancy, dribbling, or flank pain.
Musculoskeletal system –Admits to joint pain in hands and feet, as well as slight swelling. Denies arthritis, deformity, or redness.
Nervous System–Admits to tingling and loss of strength in hands and feet. Denies seizures, loss of consciousness, ataxia, change in sensation/numbness, change in cognition / mental status / memory, or asymmetric weakness.
Peripheral vascular system – Denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins, or color changes.
Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.
Endocrine system –Denies polyuria, polyphagia, polydipsia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.
Psychiatric –Denies depression, anxiety, OCD or ever seeing a mental health professional.
Physical Exam
General: 42 year old Indian male, alert and oriented to person, place and time. Patient is overweight, is well dressed, well groomed, and has good hygiene. Patient appears in no acute distress.
Vital Signs: BP: 100/70, sitting
R: 16 breaths/min unlabored
P: 77 beats/min, regular
T: 98.2 Degrees F (oral)
O2 Sat: 98% on Room air
Height: 67 inches Weight: 170 pounds BMI: 26.62 (overweight)
Skin- Warm and moist, smooth, good turgor, nonicteric. No lesions, masses, scars, tattoos, thicknesses or opacities.
Hair- male pattern baldness. No lice or seborrhea noted.
Nails- Normal color size and shape of the nails. No spooning, clubbing, beau’s lines fissures, paronychia noted. Capillary refill <2 seconds throughout hands and toes.
Head-Atraumatic, normocephalic. Nontender to palpation on the frontal, temporal, occipital, and parietal areas. No deformities or specific faces noted.
Thorax & Lungs
Chest – Symmetrical, no deformities, no evidence of trauma. Respirations are unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non- tender to palpation.
Lungs – Clear to ausculatation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical.
Abdomen-Abdomen nondistended and symmetric with no striae, scars or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Abdomen soft and non-tender to palpation across all 4 quadrants, no guarding or rebound noted.
Heart-Regular rate and rhythm. No splitting of S2 or friction rubs appreciated. Carotid pulses are 2+ bilaterally without bruits.
Mental Status Exam- patient is alert, attentive, and oriented. Speech and language are clear and fluent with good word comprehension. Appears to be in good mood, has insight and judgment into her medical problems. Memory and cognitive ability intact, gave accurate information upon assessment of history.
Peripheral Nervous System-
Motor/Cerebellar- Slightly tender to palpation on fingers and toes, slight inflammation, full AROM and full strength of fingers and toes. Full active/passive ROM of all extremities. Symmetric muscle bulk, no atrophy, tics, tremors or fasciculation. Strength 5/5 throughout upper and lower extremities bilaterally. Good gait, coordination by rapid alternating movement and point to point intact bilaterally.
Sensory-Intact to light touch, sharp/dull, and vibratory sense throughout.
Reflexes-2+ throughout.
Peripheral Vascular Exam- no edema, equal in circumference, no calf tenderness. Skin normal in color and warm to touch upper and lower extremities bilaterally. No palpable cords or varicose veins bilaterally. No palpable inguinal or epitrochlear adenopathy. No cyanosis, clubbing / edema noted bilaterally.
Labs/ Imaging
- Did bloodwork, check for electrolytes, ESR, CRP, rheumatoid factor
Assessment
42 y/o Indian male pt with Vitamin D deficiency presents to office ℅ pain in hands and feet x 3 weeks. On physical exam, slight tenderness to palpation of fingers, painful but complete AROM of fingers and toes, intact sensation. Bloodwork performed to check electrolytes and inflammatory/ autoimmune markers.
Differential Diagnoses
- Vitamin B12 Deficiency- patient has fatigue, tiredness, and weakness, as well as pain and parasthesias in hands and feet. Also, patient is an alcoholic which can cause low b12 (decreases absorption)
- Rheumatoid Arthritis- has symmetric joint tenderness in hands and feet, worse in the morning, which impairs his hand functions, and slight inflammation, as well as fatigue.
- Thiamine Deficiency- patient has peripheral parasthesias (hands and feet) and fatigue, is an alcoholic which could cause thiamine deficiency
- Spinal Tumor – parasthesias and weakness of hands and feet, but no numbness, no back pain or radiating pain down arms or legs.
- Diabetic Neuropathy- gradual parasthesias of hands and feet (“stocking glove distribution”), however,no numbness or loss of sensation (though this could happen later.) No history of diabetes, but this could be the first symptom of high blood glucose levels.
- Osteoarthritis- has pain in joints of hands and feet. But generally, osteoarthritis would not start there, did not palpate any Bouchards or Heberdens nodes.
- Multiple Sclerosis- has peripheral neuropathy, but this is typically one-sided in MS, and is not the only or main symptom
Problem List/Plan
- Hand/ Foot Pain- start Naproxen tablet 500 mg, PO every 12 hours PRN. Xray of hands to evaluate for arthritis. Labs to look for autoimmune diseases.
- Peripheral Neuropathy/ Paresthesias in hands and feet- Start methylprednisolone tablet therapy pack, 4 mg, as directed PO, for 6 days. Referral to neurologist for spinal MRI
- Vitamin D deficiency- bloodwork to check for Vitamin D levels, continue cholecalciferol
- Overweight- educate on harms associated with obesity, importance of exercise and healthy eating habits, consider referral to nutritionist
- Heavy Alcohol use on weekends- educate on harms of heavy alcohol use