Challenging Case #2

Part 1: propose a case summary including the patient’s age, gender, occupation, chief complaint, history of present illness, review of systems, physical exam, and tongue and pulse. If you also have abdominal palpation and/or channel palpation results, please include them as well. Part 2: Some examples of what I am looking for in this answer are applicable laboratory tests (e.g., Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Renal Function Panel (RFP) or imaging tests (e.g., X-Ray, Ultrasound, Computed Tomography – CT Scan, Positron Emission Tomography – PET Scan, Magnetic Resonance Imaging – MRI). If you are not the most familiar with the above, labtestsonline is a website run by the American Academy of Clinical Chemistry that will take you through laboratory medicine. For imaging test information, radiologyinfo is sponsored by the American College of Radiology and the Radiological Society of North America. Both are run by respected organizations in their respective fields. Again, please review both sites and ask whether or not appropriate laboratory and imaging tests were conducted and your rationale as to why you ask about these specific tests of your fellow classmates. Part 3: Please respond thoughtfully, using complete and grammatically correct sentences for your final analysis and diagnosis of your case. Please include what laboratory tests and imaging tests were done on your patient. If your patient did not have any laboratory or imaging tests completed, based on what you have learned, what laboratory or imaging tests should have been run to confirm the final diagnosis? Be sure to provide your rationale for your choices in your answer.

Sample Case Summary
Patient: The male patient is 56 years-old.
Chief Complaint: Achy pain in the medial instep of both feet and sharp pain at the anterior edge to heel for both feet. Numbness is also occurring on the left lateral dorsal part of the foot, radiating to the 3rd, 4th and 5th metatarsals.
Occupation: The patient is currently unemployed and very vague about prior employment. He is financially stable and does not need to work. The only information disclosed was that prior employment was an office position.
History of Present Illness: Patient indicates that this concern has been going on for the last couple of years. It has come and gone and within the last year as been a daily occurrence. He states there were no injuries that occurred to the sight. He reports it was a gradual process over the last couple of years till it became very noticeable when he didn’t wear shoes or had to wear more of a hard shoe. Currently, he cannot go barefooted as it causes pain and all shoes seem to aggravate the pain, both instep and heel. The numbness is always there and is not alleviated by anything.
Review of Systems (ROS):
Skin: non-remarkable
Head: non remarkable
Eyes: non remarkable
Ears: Non remarkable
Nose and Sinuses: non-remarkable
Mouth and Throat: non remarkable
Neck: Tight and stiff on rotating toward the right
Respiratory: non remarkable
Cardiac: non remarkable
Gastrointestinal: occasion indigestion, gas and constipation
Urinary: Urinary tract infections per patient very frequently. They come and go every couple of months
Genital: non remarkable
Bowels: occasional constipation
Pain: Pain in both feet, both shoulders, neck when turning toward the right, left side rib pain due to injury two years ago, lower back pain aggravated by activity and occipital headaches a couple of times a week
Sleep: Patient reports 8 to 9 hours sleep a night. Very beneficial
Menses: N/A
Peripheral: Vascular non remarkable
Musculoskeletal: Lifting arms overhead or holding straight out causes shoulder pain and/or weakness. Stretching to the right causes pain in the left rib cage area. There is no visible difference in shoulder joints. There is no inflammation, redness or swelling in shoulder, feet or rib cage area. Foot pain is replicated by applying pressure walking. Both feet do not have pain with being everted, inverted, dorsiflexed or contracted.
Neurological: non remarkable
Hematological: non remarkable
Endocrine: non remarkable
Psychiatric: non remarkable
Temperature: non remarkable
Sweat: non remarkable
Appetite: non remarkable
Thirst: non remarkable
Taste: non remarkable
Urination: Patient does report frequent urinary tract infections that come and go every month. He does take cranberry extract supplement daily to control symptoms.
Physical Exam
Vital Signs: Blood Pressure 116/70, Pulse is 72, Respiration: NA, and temperature is 97.5 at time of exam
General exam: Patient is alert, oriented and cooperative
Skin: Normal in appearance, texture and temperature
Neck: Patient reports tightness when rotates the head to the right. There also seems to be tightness in the trapezius on palpation as well as the cervical muscles.
Chest: N/A
Abdomen: On palpation there are is not any visible distention. Also, patient did not report any pain on palpation in any of the four quadrants.
Extremities: The fingers and toes did feel remarkably cold to the touch and patient confirmed that this has been an ongoing issue for many years.
Genital/Rectal: N/A
Cranial Nerves: N/A
Channel Palpation: There was some tenderness in liver, small intestine and large intestine meridians. Patient also reported tightness along the urinary bladder meridian in the back and gallbladder meridian down the side of both legs.
Tongue: The patients tongue is red on both sides with red tip, white thicker coat with red speckles and teeth marks. The hypoglossal veins are enlarged and purple
Pulse: The left side pulse feels wiry and thread in both heart and liver locations, kidney is very deep and fine. The right-side pulse is slippery for both the lung and spleen felt at top two positions but faint deep. The kidney on the right side is deep and fine.

Sample Solution