CHIEF COMPLAINT: Leg numbness.
SUBJECTIVE: The patient was added acutely under my schedule today for the above concern of leg numbness. It has been ongoing now for several months. She notes it is a neuropathy, burning-like pain, in bilateral feet, upper and lower as well, with radiation up to her anterior tibias bilaterally.
She does wear venous stockings for lower extremity edema. She has had worsening of her symptoms recently, and she is, of note, on Prograf for history of cardiac transplant. She has never had toxic Prograf levels recently and she follows with the cardiac surgeons. Her last Prograf level was 9.
She notes she is using Tylenol No. 3 to help with these symptoms. She states it is worse after she has been on her feet all day long.
OBJECTIVE:
VITAL SIGNS: Afebrile, pulse 86, blood pressure 112/72. Weight was refused.
GENERAL: She is in no apparent distress. Pleasant, awake, alert, oriented x3 white female.
EXTREMITIES: No clubbing, cyanosis, edema. She is wearing Jobst stockings, lower extremities, bilaterally. She has 2+ dorsalis pedis and +2 tibial pulses bilaterally.
NEUROLOGIC: Sensation is diminished to the lower extremities subjectively bilaterally in a symmetric pattern at the dorsal aspect and plantar aspect of the feet, with extension up the anterior tibia. It does not extend above the mid anterior tibia. Her cranial nerves are intact. Her gait is nonantalgic.
MUSCULOSKELETAL: No joint effusions. Full range of motion of the ankles, hips and knees. No pain with internal or external rotation.
ASSESSMENT:
1. Neuropathy of lower extremities, not otherwise specified, questionably related to Prograf.
2. History of cardiac transplant secondary to nonischemic cardiomyopathy.
PLAN: We will check noninvasive arterial studies, lower extremities, EMG and nerve conduction studies; although, we feel this is more likely neuropathy as opposed to claudication-like symptoms. She is understanding of this plan. We will follow up on the above tests. Pending that, Neurontin may be a good option for her at night, especially with nighttime symptoms.
