DATE OF EVALUATION: 11/16/2012
REFERRING PHYSICIAN: Dr. John Koch.
Dear Dr. Koch:
It is my pleasure to see Terry on November 16, 2012, for initial neurological consultation.
REASON FOR CONSULTATION: Headaches and possible small fiber neuropathy.
HISTORY OF PRESENT ILLNESS: Mr. xxxx is a very pleasant 58-year— old gentleman with a medical history notable for history of prostatitis, right—sided cubital tunnel syndrome, history of low back pain related to lumbar discogenic disease, who presents for evaluation regarding headaches and possible small—fiber neuropathy. He indicates the issues with neuropathy is one of the main reason for consultation as his headaches have improved.
He states he has had multiple symptoms for the last 20-30 years and his current picture is in the context of multiple symptoms for the last 2-3 decades. He brought copious records from other institutions including the Mayo Clinic. It turns out he has seen several neurologists including at the Mayo Clinic as well as locally.
The reason for consultation is symptoms of neuropathy and on our pain/neurological diagram, he shows symptoms certainly consistent with neuropathy including describing symptoms of numbness in both hands as well as both feet, achiness in both feet along the soles of the feet follow as well as down the middle of the spine from the neck down to the sacrum. He has recently had cubital tunnel release done as well as carpal tunnel surgery on the right side. He also has likely symptoms of cervical radiculopathy with MRI showing stenosis at the C5-C6 level. His main reason for consultation was symptoms of neuropathy with the burning pain in the hands and feet. He states this has been going on for several years. He has had extensive testing done including EMG nerve conduction study in the past at Mayo Clinic, which was normal.
He does state he was exposed to multiple different types of toxins and chemical exposures, so the idea of toxic cause of neuropathy has been entertained. Reviewing his records showS he has had extensive workup including laboratory testing for multiple causes of neuropathy. He also has multiple other medical symptoms including history of prostatitis. He has had various lesions on imaging including liver and spleen lesions. One time he had an adrenal adenoma.
Reviewing his records, I get the sense that the patient has seen multiple physicians and has not achieved a single unifying diagnosis that satisfactorily explains the constellation of symptoms, but at the same time, he has seen quite a few physicians and has had extensive testing that are well summarized in the patient’s own records as well as handouts that he handed me. For example, he has had CSF testing at one point that showed elevated protein of 137, but this was over 20 years ago. More recently at Aurora, he had a normal spinal tap.
His current symptom is primarily neurological pain in the back as well as the feet along with neuropathy described as numbness and tingling. He has also had headaches yet the headaches actually have improved this year after he was placed on Gabapentin. He has had previous MRI of the brain in 2010, which was normal. He states the headaches have lessened since June. He was diagnosed at one point with atypical Meniere’s syndrome, but the migraine headaches as well as the Meniere’s and ear problems in June have lessened with Gabapentin.
His current symptoms that he lists include neck and left scapular pain along with spine pain, migraine headaches, hearing distortion including vertigo, tinnitus, frequent urination for 20 years, hernia pain after an epicycle event in New Jersey. He had hernia surgery for his joint pain and ankles, wrists, elbows, and hands, easy bruising, alcohol intolerance, both feet still have pain. He states ulnar and medial nerve problems in the arms, although he has had again recent carpal tunnel as well as ulnar release. No history of cardiac disease listed. No personal history of stroke, seizures, or cancer.
As far as neuropathy goes, he has had testing including urine protein electrophoresis, serum protein electrophoresis, various rheumatological markers. He has been checked for diabetes. He does also indicate having significant memory problems. In fact, that was more of a complaint that his wife had where he seems both distractible as well as forgetful. For him personally, this is the one of the reason also he wanted to get seen by neurology.
DEBASISH BHATTACHARYYA, MD 12/31/2012 7:41 PM Signed
DATE OF EVALUATION: December 21, 2012.
HISTORY OF PRESENT ILLNESS: Terry was seen for follow up visit December 21, 2012. I first saw him for initial evaluation on November 16, 2012, on the kind referral of Dr. John Koch regarding headaches and possible small fiber neuropathy.
He has had a complicated medical history and has had extensive evaluation including evaluation done at Mayo Clinic including EMG nerve conduction study at one point which was normal. Nevertheless, he has had a lot of significant issues with multifocal and multifactorial pain. He has also had examination features that were consistent with neuropathy. He was diagnosed with fibromyalgia. He had self-reported that he had been diagnosed with fibromyalgia: However, we are also considering the possibility of a peripheral neuropathy related to toxin exposure. He had been in the military and had been exposed to multiple toxins at one point. He brought some VA records today that indicated that he had a direct exposure to several substances including polychlorinated biphenyls, dinitrogen tetroxide, dimethyl hydrazine, trichloral ethane, and he has had some exposure to PCBs.
On my last visit, I started him on alpha lipoic acid as a nutritional supplement. I also wrote him a topical cream to use for his pain. He has also had some carpal tunnel syndrome and ulnar neuropathy causing some superimposed pain in the arms. The topical cream consisted Ketamine 15%, Cabapentin 6%, Clonidine 0.2%, and Lidocaine 5%. He indicates the cream actually substantially helps reduce his pain by diminishing some of the paresthesia. He uses about 2 to 3 times a day and he states it actually helps substantially, more so than oral medications he has had in the past.
NEUROLOGIC EXAMINATION: Mental status: Alert, oriented, fluent speech, appropriately interactive with no dysarthria or aphasia. Judgment and insight appear intact. No apraxia was noted. Cranial nerves: Pupils equally reactive to light. Extraocular movements full, no nystagmus, no facial asymmetry. Motor: Grossly 5/5 strengthin all limbs. Coordination: No action or resting tremor. Gait: Normal gait and balance.
I did laboratory testing on him last time for some idiopathic causes of neuropathy including 2-hour glucose tolerance test, a serum protein electrophoresis, rheumatoid factor, Lyme titer. We even checked an anti—hu antibody which can often be sign a paraneoplastic sensory motor neuropathy and all of his testing was negative. He is getting back down to 80.
IMPRESSION: This is a 58—year-old with symptoms of painful peripheral neuropathy. He has had extensive neurological testing including laboratory testing for a plasma cell dyscrasia in the form of serum protein electrophoresis, paraneoplastic syndromes and anti-hu antibodies along with a rheumatological causes B12 metabolic causes and with 2-hour glucose tolerances. All his laboratory testing has been unremarkable. And yet he has clinical features of neuropathy based on history as well as exam. I did indicate to the patient that he may indeed have a toxin related neuropathy and I indicated that it may be reasonable to correlate with some of his neuropathy with previous toxin exposures into the military, although a definitive correlation can be difficult to make since it is such a remote exposure in light of the fact that has been found. There is certainly a possible link and he had evidently seen toxicologists at the VA in the past and he brought some notes where they suggested that this could be a possibility.
PLAN: At this point, I indicated if the patient has benefitted from a topical analgesic cream consisting of Ketamine 15%, Gabapentin 6%, Clonidine 0.2%, and Lidocaine 5 percent and we really need this. Hopefully, the VA will cover this for him.