Chief concern: Feet numbness HPI: Patient is a 55-year-old male who presents today with numbness in his feet. His medical history is significant for high blood pressure and type 2 diabetes that he has been managing with medication. Patient has been worked up for diabetic neuropathy before, but has noticed it getting worse. About a week ago he was backing up his truck with a trailer attached, and couldn’t feel his feet to hit the breaks, and ran into his house. His son, who was there at the time, told him he needed to go to the doctor which is why he is in today. Patient reports feeling numbness for the last 2 or 3 years, but has never had as dramatic of an episode as this one. He describes the numbness as “just can’t feel anything down there”, and says it is localized to his feet. He notices he can feel his left foot slightly more than his right. He describes having trouble stepping over things sometimes, but is mostly worried about the possibility of losing his feet. He reports no radiating numbness to any other part of his body. He reports no pain, or exacerbating factors. Patient states that he could be doing better with his diabetes management, and eats unhealthy 2-3 times per week. Patient denies fever. He denies headaches or congestion. He denies leg swelling or weight gain/loss. Past medical history: -Type 2 diabetes diagnosed 6 years ago -Hypertension diagnosed 8 years ago -Diabetic neuropathy diagnosed 2 years ago -No allergies to medications ROS: General: Reports fatigue on exertion, no fever Head: No headaches, no congestion Ears: No discharge, no pain Nose: No discharge Throat: No sore throat, no stiffness Cardiac: No chest pain, shortness of breath, no leg swelling GI: No change in bowel movements, no pain while relieving bowels Urinary: No change in frequency of urination, no painful urination Neuropsychiatric: Patient reports anxiety about his symptoms, no depression Musculoskeletal: Numbness in feet, no muscle pain, no weakness Endocrine: No excessive thirst, no weight gain/loss Physical Exam: Vitals: -BP 136/82 -Temp: 98˚ -RR: 18 -Pulse: 81 -O2 sat 98 General: Patient is alert and responsive. Patient seemed to move ok onto the exam table and off. Skin: No cyanosis on face. Nails: No cyanosis on hands or feet. Capillary refill is quick. Cardiac: Inspection: No scars. Palpation: No heaves or thrills noted, PMI is two fingers width and is regular. Carotid artery regular rate and rhythm. Auscultation: Normal S1, and S2 sounds heard over pulmonary, aortic, tricuspid, and mitral positions. No murmurs in any location. Extremities: -Upper: Good color, no rashes or bruises. Temperature is good. Radial and brachial pulses 3+ bilaterally. -Lower: Good color and temperature. Posterior tibial and dorsalis pedis pulses +3 bilaterally. Both legs measured at a circumference of 390 cm. Assessment: Patient appears to have diabetic neuropathy given his history of type 2 diabetes, and the previous diagnosis of neuropathy. Physical examination did not reveal any other potential cause to his numbness. Plan: -I would like to order a metabolic panel and H1C test for the patient’s diabetes, as well as a lipid panel for his high blood pressure. I would also like my preceptor to examine the patient’s feet for sensation. -Ensure patient has enough medication. -Educate patient on importance of taking his medication and eating healthy.
