DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Left leg paresthesias and cramps.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old right-handed Hispanic male with a history of longstanding diabetes mellitus under good control with oral medications, who was admitted for his complaints of severe left leg cramps and paresthesias. About seven to eight months ago, the patient started having some numbness in his left foot. He was seen by a neurologist and underwent a workup, including MRIs of the lumbar spine and EMG of the lower extremities which, according to the patient, came out negative. He was told that he probably had diabetes, peripheral neuropathy and was started on Lyrica. Symptoms have improved somewhat.
In the last several weeks, the patient has been complaining of waking up in the middle of the night with cramp in the left foot, mostly involving the dorsum of the lower leg. The patient also at the same time has numbness in the upper lip. These symptoms last for only a minute or two. Cramps have been increasing in frequency, and the patient got worried and stated that he wanted to get himself checked out for any serious disease.
Also, the patient has occasional numbness of the upper lip while he is doing exercise and when he is short of breath. He has been complaining of dryness of the throat and some difficulty swallowing, especially in the morning. He had swallowing test done as an outpatient which came out normal. He had seen ENT and underwent endoscopy and states that everything came out normal. The patient had also seen a pulmonologist for any lung problems and again the examination turned out to be negative. He also underwent MRI scan of the brain as well as MRA of the brain, which were also normal reportedly. The patient is not aware if he stops breathing during sleep. His wife could not give us that history either. He does not feel excessively sleepy during the daytime but states that he does have dull headache in the frontal regions most of the days.
PAST MEDICAL HISTORY: As above, history of diabetes. There is no history of heart disease, stroke, hypertension or hyperlipidemia.
CURRENT MEDICATIONS: Include antidiabetic medications, Lyrica 150 mg in the morning and 300 at night, Plavix 75 mg daily, and Foltx one daily.
ALLERGIES: There are no known drug allergies.
SOCIAL HISTORY: The patient does not smoke and does not drink alcohol.
FAMILY HISTORY: Significant for history of diabetes, but there is no history of stroke or other serious neurological disease.
REVIEW OF SYSTEMS: A complete system review was performed and no additional pertinent information was obtained. There is no recent weight gain or weight loss. No history of nausea, vomiting, diarrhea or abdominal pain. No urinary or bowel incontinence. No recent trauma.
PHYSICAL EXAMINATION:
GENERAL: The patient is a well-developed, well-nourished man who is in not in any apparent distress.
VITAL SIGNS: Normal.
NECK: Supple.
SPINE: There is no lumbar spine or paraspinal tenderness. Straight leg raising test is negative.
NEUROLOGIC: Mental Status: The patient is alert and oriented. Speech and language are normal. Cranial nerves II through XII are normal. Motor strength is 5/5, full. There is no focal atrophy or fasciculations. Tests of coordination are normal. Deep tendon reflexes are hypoactive at 0 to trace but are symmetrical. There are no pathological reflexes. Gait is normal based. Sensations are intact to pinprick throughout. There is slightly decreased vibratory sensation at the toes. Peripheral pulses are normal.
IMPRESSION:
1. Intermittent left leg muscle cramps and spasms. Rule out electrolyte abnormality or metabolic etiology. This could be due to peripheral neuropathy. Rule out periodic leg movements of sleep.
2. Probable mild diabetic peripheral neuropathy.
3. Intermittent perioral paresthesias, rule out seizures, rule out obstructive sleep apnea or symptoms secondary to hyperventilation or anxiety.
4. Subjective dysphagia.
RECOMMENDATIONS: We agree with doing an EEG and sleep study. We will check electrolytes, TSH, and ESR. We agree with decreasing dose of Lyrica to 150 mg b.i.d., which is a recommended dose for diabetic peripheral neuropathy. If not already done, should consider doing arterial Doppler studies of the left lower extremities to rule out vascular cause of the patient’s cramps and spasms. Depending on the workup, further treatment will be decided. We will consider a small dose of Klonopin at nighttime to help prevent nocturnal spasms.
