REASON FOR CONSULTATION: Bilateral feet numbness.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old right-handed gentleman who is seen in neurologic consultation today for further evaluation of numbness in his feet, which has gone for a couple of years now. He notes the distribution of this numbness along the bottom of his toes on both feet, left slightly worse than right. He has not had any numbness in his hands, except for a little bit of tingling in the fingers, not sure which fingers are involved, when riding his bike. He notes that he has his wrists extended in that posture and is putting about half of his weight on them. He has noticed the numbness on his feet while in the shower. He feels that it does not really impact his walking, except to say that the bottoms of his feet sometimes feel a little bit sore and he is not sure whether that has anything to do with the numbness.
He did see a podiatrist due to the soreness, which has been evident to him when he does a lot of walking, and mentioned the numbness in his feet. It was recommended that he see a neurologist for this.
The patient is a very active individual. He has not noticed any problems with his walking, balance, and does not have any pain in his hands, feet, or legs. He has not had any significant back problems. He denies neck pain. He has not had any bowel or bladder problems.
PAST MEDICAL HISTORY:
1. Status post tonsillectomy.
2. Hypertension.
3. Hyperlipidemia.
4. History of shoulder tendinitis.
CURRENT MEDICATIONS:
1. Losartan 50 mg daily.
2. Rhinocort Aqua p.r.n.
3. Multivitamin.
ALLERGIES: Sulfa causes hives.
FAMILY HISTORY: The patient’s father and a maternal aunt had Alzheimer’s disease, both deceased. The patient’s father also had a stroke. His mother is alive and has some back problems, but he is not aware of other medical issues. He has a sister and a brother who both have multiple sclerosis.
SOCIAL HISTORY: He denies use of tobacco. He does not use recreational drugs and drinks alcohol on occasion in moderation.
REVIEW OF SYSTEMS: Otherwise, negative, all systems.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 126/78. His has a heart rate of 66 and a respiratory rate of 16.
GENERAL: He is casually attired, appropriately groomed, pleasant, and cooperative. He looks well and is in no distress.
NECK: He has full range of motion of his neck without any vertebral or paravertebral tenderness. There is no Lhermitte sign present. There are no neck masses.
LUNGS: Clear bilaterally.
HEART: Cardiac examination reveals a regular rate and rhythm with a normal S1 and S2 and no murmur.
NEUROLOGIC: Neurologic examination was normal. Specifically, the patient is fully oriented with normal attention, language, recall and fund of knowledge. Facial sensation and strength are normal. Hearing is intact. Palate and tongue move midline. Pupils are equal and reactive to light. Extraocular movements and visual fields are full. There is no nystagmus. Funduscopic examination is benign. There is no facial weakness. There is no lower cranial nerve weakness. Sensation is normal to all modalities distally. Deep tendon reflexes are 1-2+ and symmetrical. There is no Babinski sign. Strength and tone are normal proximally and distally bilaterally. Gait is normal, including tandem, heel and toe walk. Romberg is negative. Finger-to-nose and heel-to-shin are normal. There are no carotid bruits or murmurs.
LABORATORY DATA: Normal comprehensive metabolic profile, except for a glucose of 104, nonfasting, a lipid profile with total cholesterol of 188, HDL of 52, and LDL of 124, vitamin B12 level of 800, and thyroid profile with a TSH of 2.3.
IMPRESSION AND PLAN: This is a (XX)-year-old gentleman who notes some soreness in the ball of his foot and some numbness on the plantar aspect of the toes and encroaching on the ball of his foot. We told him it is likely that the numbness is due to a bit of neuropathy. In some people, aging does cause a nonspecific small fiber sensory neuropathy. We feel that is likely what he has. We told him that this can worsen over the years. We do want to make sure that he does not have any other underlying neurologic disease. Despite his normal serum blood glucose, we will obtain a hemoglobin A1c and a monoclonal profile. With his symptoms so mild, we told him that we do not think an EMG and nerve conduction studies are warranted unless there is something abnormal in his labs. We would get an EMG if his symptoms begin to ascend significantly. At this point, he is not having any pain, so we do not feel that he needs any pharmacotherapy. We told him that for the vast majority of neuropathies, there is no treatment other than to treat any underlying medical illness. We told the patient that we would call him with the results of his testing. All of his questions were answered.
