This content is for 6-Month MOC Access members only.
Register
Register
Already a member? Log in here
Top 5 points to make:
I understand that your medical conditions are frustrating. Is there an issue with the dialysis facility that makes you not want to go? Is there anything going on in life that is making you feel sad or depressed? Do you want to kill yourself or harm anyone else? I am happy to speak with you more about any issues that I may help you with.
I can also refer you to a psychologist for further in-depth discussion of what may be bothering you.
If you are interested, I can also start you on an anti-depressant medication if it is okay with your primary doctor.
Is there anything else I can do for you?
(the key is to be empathetic and offer other resources, medical options).
Top 5 management actions to take:
This is most likely a case of uremic polyneuropathy secondary to end-stage renal disease. She most likely needs to be admitted to the acute care unit to have severe uremia managed. Addressing the cause of uremia would be to consult/communicate with the primary physician managing her CKD and dialysis. Adjusting her dialysis schedule or considering peritoneal dialysis may be beneficial.
In the mean time, symptom management may include a renal-dosed trail of a neuropathic agent.
Diabetic shoes may be offered and counseling regarding checking her feet regularly for open wounds should be provided.
Severely elevated BUN and creatinine. GFR <10
HBA1c 5.7
All other labs are normal.
EMG/NCS – Prolonged distal latencies in the sural, peroneal and tibial nerves bilaterally with normal amplitudes. Conduction velocities are slow. F-waves are normal. Absent bilateral H-reflexes. +1 PSW and fibs in the bilateral FDIs. Normal UE testing.
Lumbar imaging will be considered later if necessary.
Italicized words = examiner response.
BUN – Severely elevated.
Creatinine – Severely elevated.
GFR –Â <10
CBC/HIV/ESR/CRP/Vitamin B12/MMA/Homocysteine/Serum protein electrophoresis/RPR/TSH/Hepatitis panel – Normal.
HBA1c – 5.7
EMG/NCS – Prolonged distal latencies in the sural, peroneal and tibial nerves bilaterally with normal amplitudes. Conduction velocities are slow. F-waves are normal. Absent bilateral H-reflexes. +1 PSW and fibs in the bilateral FDIs. Normal UE testing.
Lumbar imaging – Lumbar imaging will be considered later if necessary.
Leading diagnosis: Metabolic neuropathy
Differential: Metabolic neuropathy, stroke, MI, AIDP, CIDP, lumbar radiculopathy, alcohol neuropathy. encephalitis, cancer, Wernicke’s encephalopathy, cauda equina syndrome, lumbar spinal stenosis, peripheral vascular disease, tarsal tunnel syndrome, mononeuritis multiplex, neurosyphilis
Top 5 questions to ask:
The examinee should also ask about the general exam (heart, lungs, abdomen, etc).
Vital signs:Â Blood pressure 166/88, pulse 100, sats 100% resp 12, afebrile.
Gen:Â Alert. Appears fatigued and unwell.
Cardiovascular:Â Normal. +1 distal pulses.
Respiratory:Â Normal
Abdomen:Â Normal
Extremities:Â +2 edema
Neurovascular: 20/30 Mini-Mental Exam score. Cranial nerves are intact. No cerebellar signs. 5/5 UE/LE strength. Absent reflexes throughout. No long tract signs. Impaired proprioception and sensation to light touch and pinprick in stocking-glove distribution. No tone. Normal stance, but slow gait.
Top 5Â questions to ask:
Examinee should also ask all other questions regarding the history of present illness (ROS, PMH, Meds, etc).
HPI:Â She states that she started feeling numb feet many months ago, which is now getting worse to the point that it is keeping her up at night. She also has occasional muscle cramps. Discomfort is not relieved with OTC medications. She has not had any evaluation or treatment for this previously.
ROS: + nausea, + fatigue, + weight loss, + itching. Otherwise negative.
PMH:Â CKD, HTN, HLD, DM
PSH:Â Cataract surgery, angioplasty
Family Hx:Â HTN, CAD, CKD, DM, OA, Cancer
Social Hx:Â 50-pack-year smoker. Drinks 6 beers per day. No illicit drug use. Works at a grocery store. Unmarried and lives alone in a 1-story house, no steps to enter.
Functional Hx:Â Independent.
Medications:Â She forgot to bring her medication list. But she takes all of her medications. She is on dialysis.
Allergies:Â NKDA
Top 5 points to make:
I apologize that you did not receive a copy of the note from this office visit. I made a note to have it sent to you, but for whatever reason it did not get to you. To update you, your patient is diagnosed with Parkinson’s disease and our treatment plan is to…
I will be sure to investigate this issue with my office staff to find out why you did not receive the note. I will also report this to our Quality Improvement team to improve physician to physician communication across the system.
I will resend a copy of this note for your records. Again, I apologize and please let me know if there are any further issues.
Top 5 management actions to take:
From a medication standpoint, treatment towards Parkinson’s should be aimed at improving symptoms and protecting neurons. At this point of publication, there are not proven neuroprotective agents.
Levodopa/carbidopa – (Sinemet for example)
Remember that carbidopa inhibits the decarboxylation of levodopa in the body to make levodopa more available for the CNS.
Monoamine oxidase inhibitors (MAO)-B – (Selegiline, Rasagiline, which may also have a neuroprotective effect).
Therapy is also an appropriate consideration. Specifically, therapy can improve mobility, walking speed and balance.
More importantly; however, may be to recommend a regular exercise program. Early research suggests that vigorous exercise increased the production of brain-derived neurotrophic factor, which may be neuroprotective.
MRI – Normal
Labs are within normal limits.
Italicized words = examiner response.
Although Parkinson’s disease is a clinical diagnosis requiring the signs and symptoms to meet 2 of 3 criteria (bradykinesia, rigidity, resting tremor,) further reasonable evaluation includes:
CBC, CMP, Vitamin D and Calcium (associated osteoporosis), ceruloplasmin level (Wilson’s Disease) – All of these tests are normal.
MRI brain – Normal.
Leading diagnosis: Parkinsonism
Differential: Dementia (Alzheimer’s, vascular), essential tremor, Parkinson’s inducing medication or toxin, encephalitis, brain tumor, stroke, abscess, myelopathy, intracranial hemorrhage, hydrocephalus, depression, Huntington Disease, Wilson’s Disease
Top 5 questions to ask:
The examinee should also ask about the general exam (heart, lungs, abdomen, etc).
Vital signs:Â Within normal limits.
Gen:Â Alert and oriented. Decreased blinking and facial expressions.
Cardiovascular:Â Normal
Respiratory:Â Normal
Abdomen:Â Normal
Extremities:Â Normal
Neurovascular:Â Cranial nerves are intact. No cerebellar signs, but you note an asymmetric slight tremor that improves with movement during finger to nose testing. UE and lower extremity strength is intact. Sensation is intact. Tone seems to be increased to passive movement. Vocal speech is soft, but improves with cueing. Poor posture noted on stance and gait is slow with small steps noted. Mini mental exam is normal but takes a long time to complete.
Top 5Â questions to ask:
Examinee should also ask all other questions regarding the history of present illness (ROS, PMH, Meds, etc).
HPI:Â A 53-year-old males presents to your clinic with his wife for initial evaluation of right hand clumsiness. Clumsiness started about 2 months ago and is getting worse. There is some clumsiness on the left side, but not as bad. Â He feels “foggy” overall, and is not motivated to do much. He can no longer walk 2 miles per day. His “sex life” is no more. He has never had these problems before.
ROS:Â Â + constipation, + balance problems, + slow gait, + urinary urgency, + forgetfulness, + malaise.
PMH:Â OA
PSH: Right knee arthroscopy
Family Hx:Â HTN, OA, dementia
Social Hx: Never smoked. Denies alcohol use. Married and lives with his wife. Retired.
Functional Hx:Â Prior independence.
Medications:Â Tylenol
Allergies:Â NKDA
Rehabilitation of People with Lower Limb Amputation: Braddom 3rd Edition
Some common BKA socket designs:
For BKA:
Patellar tendon-bearing
Total surface-bearing
Hydrostatic
Some common AKA socket designs
For AKA:
Ischial containment and Quadrilateral design
Gel liner
Suction suspension
Vacuum-assisted suction suspension
Fork strap with waist belt
Cuff Sleeve
Name the common feet
Single-axis
Multiaxial
Dynamic response
Name the common knees
Single-axis
Polycentric
Weight-activated stance control knee
Manual locking
Microprocessor-controlled
Name common suspension systems:
Supracondylar suspension
Supracondylar-suprapatellar suspension
Top management actions to take:
It appears that you have developed verrucouse hyperplasia. This is thought to result from a prosthesis that fits too tightly around the limb. Venous return is cut off and this skin condition develops. Let’s send you back to the prosthetist to either add an end pad to the socket or revise the socket to improve total contact. Continue to keep it clean and monitor for signs of infection.
Top 3 management actions to take:
We can most likely help to decrease pain and abnormal sensation with medical management. If the pain only bothers you at night and you can tolerate it during the day, maybe we will try and antidepressant, such as amitriptyline or mirtazapine at night. We can also try an anticonvulsant, such as gabapentin or carbamazepine. Let us know if they help or if you are experiencing any side effects from these medications.
Top 5 points to make:
Top 5 points to make:
This question is getting at pre-op counseling. Four areas should be addressed.
What should the therapy script say?
Precautions: Cardiac
PT frequency and duration
ROM, conditioning, stretching, transfers, ambulation with one-legged gait with an assistive device, upper and lower limb strengthening
Top 5 points to make:
This patient most likely has a tarsal coalition, resulting in a peroneal spastic foot. Tarsal coalition is an abnormal connection between two bones in the foot. Â The most commonly involved are the talus, calcaneus, and navicular. Â A CT or MRI should be ordered for further evaluation.
This may resolve with conservative measures. Continued therapy and ambulation in a lace-up ankle brace may help to improve range of motion. An orthopedic evaluation is warranted in the event that conservative measures fail and a surgical resection of the coalition is needed.
Any questions?
Top 5 management actions to take:
Salter-Harris Type 1 fractures should still be treated similar to a bone fracture. In this case, casting for a total of 4-6 weeks is required. If the widened physis is greater than 2mm, then an orthopedic referral is recommended.
At follow up and cast removal, repeat x-rays may be considered, but reducing radiation exposure is optimal. If there is still significant tenderness or pain with weight-bearing, a repeat x-ray is definitely reasonable.
Be sure to evaluate ROM and gait pattern, which will likely be altered. A home exercise program may be reasonable if the child is reliable. If not, a physical therapy referral can also be considered.
In kids, always consider a growth plate injury in joints that may be “sprained.”
X-rays reveal widening of the lateral distal fibula physis.
Italicized words = examiner response.
X-ray of left ankle – widening of the lateral distal fibula physis.
Leading diagnosis: Salter-Harris Type I fracture
Differential: Salter-Harris Type I fracture, lateral ankle sprain, syndesmosis injury, peroneal tendon injury, calcaneal fracture, talar fracture, cuboid dislocation, 5th metatarsal fracture, joint infection, tumor
Top 5 questions to ask:
The examinee should also ask about the general exam (heart, lungs, abdomen, etc).
Vital signs:Â Within normal limits.
Gen:Â Alert and oriented.
Cardiovascular:Â Normal
Respiratory:Â Normal
Abdomen:Â Normal
Extremities:Â Normal
Neurovascular:Â Normal
Detailed Left Ankle Exam:Â Moderate swelling. Normal skin color with mild erythema. No TTP at the proximal leg. TTP at the distal fibula. No TTP over the peroneal tendons, ATFL, CFL or PTFL. No syndesmosis tenderness. – anterior drawer, – talar tilt, – squeeze test, – eversion test.
Gait and Stance:Â Antalgic gait favoring the left leg. Normal stance.
Top 5Â questions to ask:
Examinee should also ask all other questions regarding the history of present illness (ROS, PMH, Meds, etc).
HPI:Â A 14-year-old male presents to your clinic for initial evaluation of left ankle pain for 3 weeks after injuring it playing basketball. States that he came down on the ankle “funny” after jumping for a rebound. He did not feel a crack or hear a pop, but noted immediate pain. States some benefit with ibuprofen and ice. He has been limping around on it since with moderate pain. Denies numbness or tingling. Initial x-rays in the emergency department were negative and he was diagnosed with an ankle sprain.
ROS:Â Negative
PMH:Â None
PSH:Â None
Family Hx:Â Parents are healthy
Social Hx:Â Lives with parents. In 8th grade. Makes good grades and hopes to play basketball in high school.
Functional Hx:Â No limitations.
Medications:Â None
Allergies:Â NKDA
Top 5 points to make:
I understand how you feel about this complication. I too, wish the outcome was different as this has been a difficult few years for you and your husband.
I suggest speaking with the surgeon who performed the surgery to get more clarification. As you may be aware, all surgeries and procedures have their risks and benefits, and unfortunately, a hemorrhage is a complication of surgery.
As far as suing, I can’t say because I don’t know all of the facts surrounding the surgery and complication. However, I am glad to help your husband get better from here on out from a rehab standpoint.
Any questions?
Top 5 management actions to take:
Considering his gradual decline in function it is quite reasonable to strongly consider recommending intervention. If headaches were the only presenting symptom, more conservative management may be best. The risks and benefits must be explained, and this may be beyond the physiatrist’s scope alone.
According to Emedicine.com:Â
Treatment of AVMs is best achieved with a multispecialty team comprising a neurologist, neuropsychologist, neurosurgeon, interventional neuroradiologist, and neuroanesthesiologist.
Headache management should follow standard headache/migraine headache protocols.
A speech therapy referral is also reasonable considering his academic decline and deficits in reading, writing and recognizing symbols.
CT – normal, no acute hemorrhage
MRI – Consistent with a small subcortical arteriovenous malformation in the left parietal lobe.
Labs are within normal limits.
Italicized words = examiner response.
CBC/CMP/ESR/CRP/serum protein electrophoresis/rheumatoid factor/ANA/TSH – Normal.
CT – Normal, no acute hemorrhage.
MRI – Consistent with a small subcortical arteriovenous malformation in the left parietal lobe.
Leading Diagnosis: Headache disorder
Differential: Migraine headache, cluster headache, tension headache, occipital neuralgia, cardioembolic stroke, intracranial hemorrhage, cerebral aneurysms, cerebral AVM, dissection, Moyamoya disease, amyloid angiopathy, fibromuscular dysplasia, abscess, tumor, encephalitis
Top 5 questions to ask:
The examinee should also ask about the general exam (heart, lungs, abdomen, etc).
Vital signs:Â Within normal limits.
Gen:Â Alert and oriented.
Cardiovascular: Normal
Respiratory:Â Normal
Abdomen:Â Normal
Extremities:Â Normal
Neurovascular: Cranial nerves are intact. No cerebellar signs. Strength is intact. Sensation on the right is slightly impaired in comparison to the left. + agraphesthesia. + astereognosis. Has difficulty taking off his shirt. + Hoffman’s reflex. Fair trunk control. There may be a component of right-sided neglect, but the exam is inconsistent. – Romberg, – pronator drift. Stance appears normal. Gait appears normal.
Top 5Â questions to ask:
Examinee should also ask all other questions regarding the history of present illness (ROS, PMH, Meds, etc).
HPI:Â A 20-year-old male presents with his girlfriend (who insisted that he see a doctor) to your clinic in referral for further evaluation of occasional headaches and worsening grades in school. He achieved a 5.0 GPA in his senior year of high school and was able to transfer 30 AP credits from high school to college. He has aspirations to become a NASA engineer. Over the past 10-12 months he has noticed a decreased ability to pay attention, mental fogginess, and occasional moderate to severe left-sided headaches that have resulted in a decline in his grades. He particularly is having problems with math, reading, writing and understanding symbols. Headaches are intermittent without association. He denies a history of headaches or head trauma. He was previously diagnosed with migraine headaches, but medications do not help. He is concerned that there is something else going on.
ROS:Â Negative
PMH:Â None
PSH:Â None
Family Hx:Â Negative for migraines. All parents and grandparents are healthy. Siblings are healthy.
Social Hx:Â Denies tobacco, alcohol or drug use. Lives with his girlfriend in an apartment. Full-time college student. States that he will lose his scholarship if his grades don’t improve.
Functional Hx:Â Prior independence.
Medications:Â Fioricet without benefit. No relief with OTC pain medications.
Allergies:Â NKDA
Top 5 points to make:
The health of your brain is most important. Researchers are still learning a lot about the long-term effects of concussions, and more specifically, repeated concussions. There are quite a lot of unknown variables. Â What we know is that each concussion you sustain makes you more vulnerable to another concussion and the symptoms usually remain longer than the previous.
With that being said, I recommend further evaluation with MRI testing, neuropsychological testing and a neurology referral. It is best to make sure that there are no underlying causes for your frequent concussions and to have more than one doctor’s opinion regarding your continued play.
Overall, this is a tough decision that only you can make. Any questions about this?
Top 5 management actions to take:
Concussion management is rapidly evolving. However, the athlete should certainly be removed from play and not allowed to return for the rest of the day regardless of the circumstance. She should be monitored closely for any concerning change in status. She should be in the care of another responsible adult until symptoms resolve.
The mainstay of treatment is cognitive rest, and this may be relative. In general, advising to avoid alcohol use, physical activity and school is recommended. These activities can prolong healing, and may even exacerbate symptoms. Â In addition, screen time should be minimized as much as possible with no screen time 1 hour prior to bed time to encourage restorative sleep.
Medications have not been shown to speed recovery, but can help with headache symptoms. It is probably best to avoid NSAIDs and prefer acetaminophen in the case of an intracranial hemorrhage.
“Being comfortable, and taking it easy” is probably the best advice at this point. Advising all-day sleep in a dark room may not be necessary for speed recovery. This, of course, is admittedly debatable.
Once symptoms resolve, or if symptoms last more than 7-10 days, the athlete should return to your clinic for further assessment. The SCAT3 should be repeated, as well as, a computer-based concussion evaluation. If the athlete is back to baseline, the return to play protocol can be instituted.
If symptoms last more than 7 days, a review of the rest period may reveal improper rest (such as going out with friend to drink alcohol, or continuing to exercise). If the athlete rested properly, considering further evaluation with an MRI or neuropsychological testing should be considered. Further counseling regarding post-concussive syndrome and second impact syndrome should be provided.
Further evaluation remains an area of controversy and should be decided on a case to case basis. In general, a CT scan would be the imaging modality of choice. Strong consideration for ordering a CT scan without contrast should be considered if the GCS score is less than 15. In this case, she was not fully oriented which resulted in her loss of a GCS point. If there are focal neurologic findings or a deterioration in clinical status, a CT scan should be ordered.
No blood work is particularly indicated.
Leading diagnosis: Moderate or severe TBI
Differential: Moderate or severe TBI, migraine headache, cluster headache, intracranial hemorrhage, epidural hematoma, subdural hematoma, spinal cord injury
Top 5 questions to ask:
The examinee should also ask about the general exam (heart, lungs, abdomen, etc).
Vital signs:Â Within normal limits.
Gen:Â Appears uncomfortable and excessively fatigued.
Cardiovascular:Â Normal
Respiratory:Â Normal
Abdomen:Â Normal
Extremities:Â Normal
Neurovascular: There is no cervical tenderness. Cranial nerves are intact. No cerebellar signs. Strength and sensation are intact. Here balance exam is significantly abnormal in comparison to baseline testing.
Top 5Â questions to ask:
Examinee should also ask all other questions regarding the history of present illness (ROS, PMH, Meds, etc).
HPI: You are the team physician for a local college soccer team. During a match you witness your star forward go for a header and hit the elbow of a player on the opposing team. She immediately grabs her head and stumbles towards the sideline. You take her into the locker room for further assessment.
She states that she has a headache, feels nauseous, vision is blurry, she feels foggy and her balance is not quite right. She also feels that the lights in the room are making things worse.
ROS: –Â neck pain, – loss of consciousness. Remaining quick review of systems are negative.
PMH:Â None
PSH:Â ACL surgery
Family Hx:Â HTN
Social Hx:Â She drinks when she goes out with her friends on the weekends. Does not smoke. Lives in a dorm with a roommate.
Functional Hx:Â College athlete.
Medications:Â None
Allergies:Â NKDA
She completes the SCAT3:
GCS: 14
Maddock’s Score: 2
Symptom score of 16 and severity score of 88. 3 orientation score. Immediate memory 11, concentration score for digits backward of 2 and months in reverse score of 0. Delayed recall score of 1.
Top 5 points to make:
First and most important is to make sure that you do not violate confidentiality laws. Be sure to ask the patient if it is okay for you to answer that question in front of others if this has not already been expressed.
Overall, the prognosis for near to full recover is good. Each case is different, but we expect your strength and ability to function to continually improve day to day. We will no more as time progresses. We typically see the most recovery in the first 6 months to one year. Â In the mean time, keep doing your best in therapy and continue to learn as much as you can about your condition. Any questions?
Top 5 management actions to take:
Neurosurgery/orthopedic surgery should be consulted to evaluate the surgical indication on a case by case basis. Studies conflict in comparing no surgery vs early surgery vs late surgery in recovery. Generally, if a patient is functionally improving, most surgeons would not intervene.
An inpatient rehabilitation admission if vital in recovery. PT/OT and speech therapist should be consulted. Physical and occupational therapists will help to address the unique issue of immobility associated with patients with central cord syndrome. Because hands are generally weaker than legs, patients have difficulty using an assistive device to ambulate and a platform walker is preferred. The fall risk is high in these patients. Completing ADLs with a likely cervical orthosis or recent cervical fusion can also present as a barrier to progress.
Medically, these patients often have a neurogenic bowel and bladder; however, 52-84% recover urinary function. Issues with skin, neuropathic pain and spasticity must also be addressed.
X-ray – Severe multilevel degenerative disc disease with spondylosis.
CT – C3 extension teardrop fracture.
MRI – Increased signal intensity within the cord at the C3 level.
Labs are within normal limits.
Italicized words = examiner response.
CBC/CMP/ESR/CRP – Normal.
X-ray – Severe multilevel degenerative disc disease with spondylosis.
CT – C3 extension teardrop fracture.
MRI – Increased signal intensity within the cord at the C3 level.
Leading diagnosis: Central Cord Syndrome
Differential: Multi-level cervical radiculopathy, multilevel lumbar radiculopathy, spinal stenosis, cervical root avulsion, abscess, tumor
Top 5 questions to ask:
The examinee should also ask about the general exam (heart, lungs, abdomen, etc).
Vital signs:Â Within normal limits.
Gen:Â Alert and oriented.
Cardiovascular:Â Normal
Respiratory:Â Normal
Abdomen:Â Normal
Extremities:Â Normal
Neurovascular:Â Cranial nerves are intact. No cerebellar signs. 1/5 bilateral hand grip, finger flexion and finger extension. 2/5 bilateral elbow flexion and extension. 2/5 wrist extension. 3/5 bilateral lower extremity strength. Impaired sensation from the clavicle to the sacrum, but intact. Voluntary anal sphincter contraction intact. Absent reflexes throughout. + Hoffman’s reflex. Fair trunk control.
Top 5Â questions to ask:
Examinee should also ask all other questions regarding the history of present illness (ROS, PSH, Meds, etc).
HPI:Â You are consulted on a 68-year-old male with new onset bilateral hand more than leg weakness after a slip and fall in his driveway yesterday. States that he did not hit his head, but has mild neck pain, as well as, numbness and tingling in both arms and legs. He also has not had a bowel movement since the injury. No other trauma was sustained.
ROS: + neck pain, + constipation, + balance problems. Otherwise negative.
PMH:Â Cervical degenerative disc disease, cervical spondylosis
PSH:Â Right knee TKA
Family Hx:Â HTN, OA
Social Hx: Never smoked. Denies alcohol use. Married and lives with his wife who requires a walker for ambulation. Live in an apartment with an elevator.
Functional Hx:Â Prior independence.
Medications:Â HCTZ, occasional Mobic
Allergies:Â NKDA
Top 5 points to make:
Yes sir, you are right that there has been some evidence of immunosuppressive therapy being beneficial in helping to improve pain. However, in reviewing all of the available evidence, a Cochrane review reported that evidence was lacking concerning benefit of immunosuppressive therapy. Also, immunosuppressive therapy is not without risks. This should improve with time, improved blood glucose control and therapy. If you would like a second opinion, please feel free to get one. My office staff can help you schedule this if you would like. Any questions about this?
Top 5 management actions to take:
Recovery from diabetic amyotrophy can be slow. Management of blood glucose is of utmost importance in treatment. Diet and exercise habits should be addressed. It is reasonable to consult an endocrinologist to help with management considering his poor control. While he lost 40 pounds (which raises concern for cancer), extensive weight loss can be associated with diabetic amyotrophy. But cancer needs to be ruled out.
From a rehabilitation standpoint, he has fortunately not lost enough independence to require an inpatient admission; however, if he were worse, this could be considered. Instead, he should be prescribed an assistive device to assist with ambulation and sit to stand maneuvers. He would likely benefit from outpatient physical therapy to assist with strengthening, stretching exercises and to also help with gait training.
He should also be prescribed diabetic shoes and be counseled on the importance of checking his feet daily.
Nerve pain can also be addressed with various medications (gabapentin, capsaicin, etc.).
Lab work reveals an HbA1C of 12.1 and elevated glucose levels. X-rays show mild osteoarthritis. On T2-weighted MRI scan of the right hip, high signal intensities could be seen in the bilateral hamstrings and the adductor magnus and right tensor fasciae latae, as well as in the extensor muscles of the lower legs. EMG/NCS shows positive sharp waves and fibrillation potentials in the iliopsoas, hip adductors, and quadriceps. Sural nerve responses are absent and peroneal and tibial nerve have prolonged latencies. The right ulnar nerve sensory latency and motor latency are also prolonged.
Italicized words = examiner response.
HbA1C – 12.1
CMP – Elevated glucose levels.
CBC/ESR/CRP/rheumatoid factor/ANA/TSH/vitamin B12 – Normal.
X-ray of hips/pelvis/lumbar spine – Degenerative disc disease and mild OA in the bilateral hips.
MRI – Signal intensities could be seen in the bilateral hamstrings and the adductor magnus and right tensor fasciae latae, as well as in the extensor muscles of the lower legs.
EMG/NCS – Positive sharp waves and fibrillation potentials in the iliopsoas, hip adductors, and quadriceps. Sural nerve responses are absent and peroneal and tibial nerve have prolonged latencies. The right ulnar nerve sensory latency and motor latency are also prolonged.
ABIs – Deferred.
Leading Diagnosis: Diabetic amyotrophy
Differential: Multi-level lumbosacral radiculopathy, lumbar spinal stenosis, Limb-Girdle Muscular Dystrophy, Guillain-Barre Syndrome, myopathy, peripheral neuropathy, motor neuron disease, abscess, hematoma, tumor
Top 5 questions to ask:
The examinee should also ask about the general exam (heart, lungs, abdomen, etc).
Vital signs:Â Within normal limits, with the exception of a blood pressure of 168/100.
Gen:Â Alert and oriented.
HEENT:Â Cotton wool spots noted on fundoscopic exam.
Cardiovascular:Â Normal
Respiratory:Â Normal
Abdomen:Â Normal
Extremities:Â +1 bilateral pitting edema.
Bilateral Hip: Atrophy appreciated of the right thigh. No tenderness to palpation. Passive and active ROM is full.
Neurovascular:Â Cranial nerves are intact. No cerebellar signs. Impaired non-dermatomal sensation noted on monofilament testing of both feet. Impaired proprioception bilaterally. Normal sensation of both legs otherwise. 4/5 right hip flexion, hip extension and knee extension. Otherwise, 5/5 strength in the lower extremities. Unable to palpate distal lower extremity pulses, but +1 bilateral radial pulse.
Gait and stance:Â Difficulty getting out of a chair without using his hands and arms. Gait is slow and wide-based.
Top 5Â questions to ask:
Examinee should also ask all other questions regarding the history of present illness (ROS, PMH, Meds, etc).
HPI:Â A 73-year-old man presents to your clinic for further evaluation of right leg pain and weakness. He states right, fairly constant, hip, buttock and thigh pain and weakness that began without a traumatic event 3 months ago. Symptoms are worsening and make getting up out of bed and out of chairs difficult. Symptoms are also present on the left, but not as severe. He also reports numbness and tingling in his toes that he thinks is “sciatica.”
ROS:Â +Â 40 pound weight loss, + excessive thirst, + excessive urination, + fatigue. Otherwise negative.
PMH:Â Uncontrolled type 2 diabetes, HTN, HLD
PSH:Â None
Family Hx:Â Diabetes, heart problems, cancer
Social Hx:Â Never smoked. Drinks on occasion. No illicit drug use. Lives alone in a 1-story house. No steps to enter. Retired hotel manager.
Functional Hx:Â States that he cannot walk as far as he used to because of weakness in his legs. Difficulty getting out of a chair.
Medications:Â Insulin, statin, aspirin, ACE inhibitor
Allergies:Â NKDA
Top 5 points to make:
Thank you for your question. There is a graded chart that includes pitch count recommendations related to age. I do not know the exact numbers, but I can give you a reference before you leave today. Also please give this reference to your child’s league administrators as these rules should be used for all players. I am also happy to write his limitations on a prescription pad if needed. Any questions?
Top 5 management actions to take:
This is a straightforward case of Little Leaguer’s Shoulder, or more specifically, a Salter-Harris I proximal humeral fracture. The x-ray in this case does confirm the diagnosis. It also helps to decrease the likelihood of a tumor or fracture. An MRI/MRA is not necessarily indicated at this point considering the provided history, exam and x-ray findings. However, if symptoms do not gradually improve, an MRI/MRA may be ordered to consider other pathology.
For treatment, rest is best. Depending on the severity of pain, a sling for a short time may be helpful. Physical therapy should be initiated, for stretching in the initial stages. Once asymptomatic, a graduated throwing program can be initiated. It must be stressed that pain is the limiting factor in progression.
The x-ray shows widening of the proximal humeral physis.
Italicized words = examiner response.
Radiography – Shows widening of the proximal humeral physis.
MRI/MRA – Deferred for now.
Leading diagnosis: Little leaguer’s shoulder
Differential: Rotator cuff tendinitis, subacromial bursitis, bicipital tenosynovitis, labrum injury, AC joint injury, thoracic outlet syndrome, cervical myofascial pain, suprascapular neuropathy, infection, tumor
Top 5 questions to ask:
The examinee should also ask about the general exam (heart, lungs, abdomen, etc).
Vital signs:Â Within normal limits.
Gen:Â The general physical exam is within normal limits.
Right Shoulder:Â No gross abnormality. Generalized tenderness to palpation at the proximal humerus. Passive and active range of motion is full, without pain. 5/5 strength. Sensation and reflexes are normal. +2 radial pulse. No pain with empty can maneuver, active-resisted external rotation intact without pain. – Speed’s, – Yergason’s. – cross arm. – impingement. – lift off test. – O’Brien’s.
Top 5Â questions to ask:
Examinee should also ask all other questions regarding the history of present illness (ROS, PMH, Meds, etc).
HPI:Â A 14-year-old male, right-handed pitcher presents to you today with his parents for further evaluation of right shoulder pain. He states that he pitched in a state tournament this past weekend and noted an insidious onset of right shoulder pain without trauma. He had to take himself off the mound after the 4th inning of the third game that day because of shoulder pain. States a constant right shoulder pain that is worse with movement and better with rest and OTC pain medications. Denies numbness, tingling or weakness. Denies neck pain.
ROS:Â Negative
PMH:Â None
PSH:Â None
Family Hx:Â No medical problems in his family
Social Hx:Â Lives with parents. Makes good grades. All-star pitcher.
Functional Hx:Â No limitations.
Sport-specific Hx:Â Has played baseball since he was 4. He does not keep a pitch count. He is the number 1 pitcher in the area for his age group.
Medications:Â None
Allergies:Â NKDA
Top 5 points to make:
I understand that you have been through a lot these past few months. It is also unfortunate that your discharge plans are limited.
Because of your limited discharge options, I am happy to call the medical director of your insurance company to see if we can extend your stay to help you achieve another level of function. In the event that a nursing home is your only option, you will then be able to take better care of yourself without much assistance if your function improves with an extension.
Also, many young people in your similar situation are in nursing homes while they recover. It is still early in your disease course, so there is still a chance that you can improve. If you are willing, continue to contact family members and friends that may be able to help you. We will also continue to look for various resources through medical societies that may be able to help. Do you have any questions about this?
Top 5 management actions to take:
This is a complicated case considering that the absolute diagnosis is unclear. However, it is clear that there is a non-traumatic spinal cord myelopathy. Neurology should be consulted and the patient monitored closely.
Considering the characteristics of the lesion on MRI, chances are this is an early presentation of multiple sclerosis. The plaque is characteristically located in the dorso-lateral cord and does not expand more than 2 segments. Lesions in transverse myelitis typically expand 3-4 segments. Although the brain MRI is negative, lesions that involve solely the spinal cord are present in 5-24% of patients.
Keep in mind that dissemination of lesions/attacks in time are important in diagnosing MS. Because there is one lesion and only one attack, transverse myelitis is most likely the proper diagnosis at this point. However, it is important to counsel the patient that MS is still a possibility.
As far as treatments, aggressive immunosuppression (IV corticosteroids, plasma exchange) would be the initial treatment for both transverse myelitis and MS.
In addition, a rehabilitation admission should be considered after acute treatments are complete. She will not only need daily PT/OT, but will also need to learn how to manage her bowel and bladder. A wheelchair evaluation/assistive device is also appropriate depending on her functional level at discharge.
Leading Diagnosis: Multiple sclerosis
Differential: Multiple sclerosis, neuromyelitis optica, spinal cord infarct, abscess, tumor, disc herniation, syrinx, vasculitis, AV fistula, conversion disorder
The brain MRI is normal. The T-spine MRI reveals a dorsolateral T7/T8 level lesion that does not transverse the entire cord. Blood work is normal.
Italicized words = examiner response.
CBC/CMP/ESR/CRP/RF/ANA/TSH/Vitamin B12/antibodies against aquaporin 4/copper studies – Normal.
MRI (Brain, C-spine and T-spine) – The brain MRI is normal. The T-spine MRI reveals a dorsolateral T7/T8 level lesion that does not transverse the entire cord.
SSEP – Deferred for now.
Top 5Â questions to ask:
Examinee should also ask all other questions regarding the history of present illness (ROS, PMH, Meds, etc).
Vital signs:Â Within normal limits.
Gen:Â Appears anxious. Presents in a wheelchair. Alert and oriented.
Abdomen: Mildly distended. Tenderness to palpation of the left lower quadrant. Dullness to percussion.
Back:Â No gross abnormality. No step-off. No tenderness to palpation. ROM is full without pain.
Neurovascular:Â Cranial nerves are intact. No cerebellar signs. Stocking-glove distribution parasthesias from the T8 dermatome sensory level to the sacral level. Strength testing reveals 2/5 lower extremity strength. +3 reflexes in the lower extremities. + sustained clonus. – Hoffman’s sign. Proprioception impaired. Â Posterior tibial pulse is +1.
Gait and stance: Unable to bear weight because of weakness.
Top 5Â questions to ask:
Examinee should also ask all other questions regarding the history of present illness (ROS, PMH, Meds, etc).
HPI: An 18-year-old female presents to your clinic in referral from her primary care physician for further evaluation of mid-back pain. In the middle of the night 2 days ago, she awoke with sudden mid-back pain and urinary incontinence. When she got up to use the bathroom, she fell because her legs were weak. No injuries were sustained in the fall. Since that night, she has been incontinent  of urine but her bladder “feels full” and she has not had a bowel movement since. She received some benefit from gabapentin for numbness and tingling in the legs. She has been wearing shorts because the feeling of cloth is uncomfortable on her legs. She denies trauma.
ROS:Â +fatigue. Otherwise negative.
PMH:Â Healthy, but thinks that she had the flu a few weeks back.
PSH:Â None
Family Hx:Â No medical problems in her family.
Social Hx:Â AÂ freshman in college. Denies drug or alcohol use.
Functional Hx:Â No limitations.
Medications:Â None
Allergies:Â NKDA
Top 5 points to make:
First, taking opiate medications that are not yours is a federal offense and I recommend that you stop immediately taking your dad’s medications. You may also advise your dad that he should be the only one taking medications prescribed to him. I do understand that your pain can be difficult to tolerate, but let’s work together to come up with a better solution to control your pain. Research is conflicting concerning the use of opiates for CRPS. Because of the risks associated with chronic opiate use, let’s continue to try different non-opiate measures to help treat your pain. Later on, it may be reasonable to try opiates if they have worked for you. We are going to get you through this. Any questions?
Top 5 management actions to take:
Early ambulation is of utmost importance in treating CRPS. After this, there is not much evidence for appropriate treatment. However, the available evidence suggests the most benefit from:
Other modalities for treatment are also available. View in more detail.Â
Italicized words = examiner response.
CBC/ESR/CRP/RF/ANA/complement fixation panal/serum electrophoresis/HBA1C – Normal.
Ankle x-ray – Normal.
MRI ankle – Normal. No signs of stress fracture.
Triple-phase bone scan/EMG/NCS/vascular studies/compartment pressures – Deferred for now.
Leading diagnosis: Complex regional pain syndrome
Differential: CRPS, peripheral vascular disease, mononeuropathy, compartment syndrome, radiculopathy, infection, diabetes, neuroma, vasculitis, toxic exposure, demyelinating peripheral neuropathy, Lyme’s Disease
Top 5 questions to ask:
The examinee should also ask about the general exam (heart, lungs, abdomen, etc).
Vital signs:Â Within normal limits. General physical exam is normal.
Detailed Exam of the Right Foot:
Inspection:Â + hyperhidrosis, +edema, mottled appearance to the skin, + bluish appearance to the skin, + atrophy of the foot and lower leg muscles.
Palpation:Â Right foot feels colder than the left.
ROM:Â Active plantarflexion is full, dorsiflexion is limited to neutral both active and passively. There is weakness is active eversion. Inversion is full.
Neurovascular:Â Stoking-glove distribution hypoesthesia. Proprioception intact. Intact +1 Achilles reflex. No clonus. Posterior tibial pulse is +1. The remainder of the neurological exam is within normal limits.
Gait and stance:Â Unable to bear weight on the affected foot.
Top 5Â questions to ask:
Examinee should also ask all other questions regarding the history of present illness (ROS, PMH, Meds, etc).
HPI:Â An 18-year-old female presents to your clinic for a second opinion regarding chronic right foot pain. She is a gymnast who sustained a fall off of a balance beam during practice 3 months ago. When she fell, the beam struck the outside of her right leg, just below the knee. Immediately after, she experienced numbness on the top of the foot and weakness with raising the foot up and “turning the foot out.” She has been unable to ambulate on the right foot because of unbearable tingling. The emergency department diagnosed her with a “leg contusion” and follow up physicians have diagnosed “chronic leg pain.” She heard that you are a great physician from a friend and is here for your diagnosis and management opinion.
ROS:Â + swelling, +skin sensitivity, +color and temperature changes, + pain, +numbness and tingling, +abnormal sweating. Otherwise negative.
PMH:Â Asthma
PSH:Â Tonsillectomy
Family Hx:Â Father has hypertension
Social Hx:Â A senior in high school. Denies drug or alcohol use.
Functional Hx:Â No limitations.
Medications: None
Allergies:Â NKDA
The most common complications include:
Top 5 points to make:
In the case of post-stroke depression, anti-depressant medication is more appropriate than psychotherapeutic intervention. Psychotherapeutic intervention is both expensive and requires a significant amount of staff time and expertise. Further, improvements may take many weeks.
Top 5 management actions to take:
The main goal of stroke therapy is to restore blood flow to the brain and preserve the penumbra. tPA, and intra-arterial recanalization techniques are best when performed early to save ischemic brain cells. Stroke evaluation should be completed within 60 minutes upon hospital arrival and tPA given within the first 3 hours if appropriate. An anti-platelet agent should be given. The threshold for blood pressure control is 220/120, as too low of a blood pressure or strict control can decrease blood flow to the penumbra.
Occupational therapy, physical therapy, speech therapy, and physical medicine and rehabilitation experts should be consulted within the first day of hospitalization.
Imaging is consistent with an left MCA territory ischemic infarction.
Italicized words = examiner response.
Noncontrast CT –Â Consistent with an left MCA territory ischemic infarction.
CBC – Normal.
CMP – Normal.
Cholesterol Panel – Elevated LDL.
HbA1c – 5.4%.
MRI/Carotid ultrasound/TEE – Deferred for now.
EKG – Irregular, irregular rate.
Leading Diagnosis: CVA
Differential: hemorrhage, seizure, Bell’s palsy, brain neoplasm, systemic infection, migraine, syncope, vertigo, toxic metabolic disorders (hyponatremia,hypoglycemia, etc), transient global amnesia, conversion disorder
Top 5 questions to ask:
The examinee should also ask about the general exam (heart, lungs, abdomen, etc).
Vital Signs:Â 99.6 F, 180/110, 99P, 18 R, PO2 98% on 2L NC
General:Â Laying in bed, no acute distress. Well-nourished. Appropriate appearance for age.
HEENT:Â No cranial trauma. Right lower facial droop. EOMI. Ipsilateral hemianopsia. Hearing intact. Nares clear. Throat clear.
Respiratory:Â Normal.
Cardiovascular:Â Irregularly irregular rate. Grade I systolic murmur. No gallops. No carotid bruit. No abdominal bruit. Distal pulses intact.
GI:Â Abdomen soft and non-tender. + Bowel sounds.
Extremities:Â +2 edema. No cyanosis.
Neurological: GCS 15. NIHSS 11. Could not perform finger to nose testing on the right, but intact (slow) on the left. Impaired right upper and lower extremity sensation to light touch and pinprick. Impaired proprioception. 0/5 right upper extremity strength. 2/5 right lower extremity strength. Brisk reflexes on the right. + Hoffman’s, + clonus on the right. + Romberg. + pronator drift. Impaired stance and unable to ambulate. Follows requests, but difficulty with expressive speech.
Top 5Â questions to ask:
Examinee should also ask all other questions regarding the history of present illness (ROS, PMH, Meds, etc).
CC: Right Side Weakness
HPI: A 72-year-old male woke up 1 hour ago with a weak right leg that he was able to move, but was unable to move his right arm. His wife reports that his speech was slurred and drooping on the right. He also was having difficulty “getting words out.” He has never experienced these symptoms before.
ROS:Â + incontinence, + difficulty swallowing. Otherwise negative.
PMH:Â HTN, HLD, uncontrolled diabetes, CAD
PSH:Â Coronary arthroplasty
Medications:Â Beta-blocker, ACE-inhibitor
Allergies:Â NKDA
Family Hx:Â Brother with diabetes. Both parents died of “natural causes.”
Social Hx:Â Lives with his wife. 60 pack-year smoking history. Denies alcohol or illicit drug use. Retired.
Functional Hx:Â States knee pain when walking long distances. Otherwise, no limitations.
Cardiac rehabilitation involves 3 different phases to help you recover.
Phase 1 takes place in the hospital setting and is focused on intense cardiac monitoring. Early mobilization, such as walking around the room and up and down stairs get you moving early. Once you are stable for discharge you will enter the second phase of cardiac rehabilitation.
Phase 2 involves going to an outpatient cardiac rehabilitation center 3 times a week for 12 weeks. Here you will perform about 30 minutes of exercise on a treadmill or exercise bike while having your heart monitored with telemetry. A nurse will monitor your heart and a cardiologist is always on-call. You will also receive education regarding ways to lead a heart-healthy lifestyle.
Phase 3 occurs once you have finished 3 months of outpatient cardiac rehabilitation and is focused on continuing to exercise and lead a heart-healthy lifestyle on your own. You will learn how to exercise at home or in a gym. From here you will continue the healthy habits that you have formed over the past few months.
Cardiac rehabilitation has been shown to help in various research studies and is supported by the American Heart Association.
Any questions?
Cardiac rehabilitation should now be considered.
Italicized words = examiner response.
CBC – Normal.
CMP – Slightly elevated BUN and creatinine. Glucose 140.
EKGÂ – ST elevations in V1-V6 and early Q waves in V2 and V3. Cardiac enzymes are elevated.
Cardiac cath –Â 80% LAD stenosis and 60% RCA and LCA stenosis.
Echocardiogram – Ejection fraction of 50%.
Further reasonable evaluation includes:Â EKG, cardiac catheterization, echocardiogram, cardiac enzymes, BMP. CMP, BNP, chest x-ray, KUB.
Leading Diagnosis: Myocardial infarction
Differential:Â MI, CHF exacerbation, hypoglycemia, anxiety, aortic dissection, dyspepsia, endocarditis, arrhythmia, pancreatitis, myocarditis, pneumonia, pneumothorax, gastroenteritis, gastroparesis, pulmonary embolism
Top 5 questions to ask:
The examinee should also ask about the general exam (heart, lungs, abdomen, etc).
Vitals:Â Afebrile. Pulse 120. Respiration 24. BP 168/95. Pulse oximetry 91% on 2L NC.
Gen:Â Mild distress. Diaphoretic.
HEENT:Â Normal.
Cardiovascular:Â Tachycardic. Regular rhythm. No M/R/G.
Respiratory:Â Tachypneic. CTAB.
Abdomen:Â Normal.
Extremities:Â +1 edema
Psych:Â Anxious
Neuro:Â No focal deficits.
Top 5Â questions to ask:
Examinee should also ask all other questions regarding the history of present illness (ROS, Meds, etc).
HPI:  A 59-year-old male presents to the hospital with worsening nausea and shortness of breath. He just caught a big fish and first attributed his symptoms to his excitement and fatigue, but nausea continued to worsen. He decided to leave early, and by the time he got home he noticed that he was also short of breath. When he reached the emergency room, he still did not have chest pain, but symptoms continued to progress.
ROS:Â + anxiety, +shortness of breath, nausea. Otherwise negative.
PMH:Â Uncontrolled diabetes for 20 years, HTN – 30 years, HLD – 20 years
PSH:Â None
Family Hx:Â Mother with diabetes. Father died of MI at age 62.
Social Hx:Â Lives alone. Â Retired deck hand. Smokes 1 pack per day for 40 years. Drinks 3 beers per day. No illicit drug use.
Functional Hx:Â No limitations.
Medications:Â Insulin, statin, ACE-inhibitor
Allergies:Â NKDA
Top 5 points to make:
The physician should always attempt to avoid giving false hope when discussing prognosis and functional return. Unfortunately, the data we have about functional prognosis after spinal cord injury is in the traumatic spinal cord injury population and not the vascular population. Although this patient has a compression mechanism, he also has signs of ischemia on MRI/MRA. You should inform the patient that his function after surgery, his AIS exam after surgery, and functional return over the next few weeks will be very helpful in further addressing the question.
As always, ask if there are other concerns/questions.
Top 5 management actions to take:
A vascular surgery/neurosurgery consult should be placed urgently to evaluate for possible decompression. In addition, foley should be kept in place and the patient should be started on a bowel regimen for upper motor neuron bowel. Pressure relief ankle foot orthosis should be applied and skin care should be undertaken.  Consult PT/OT when appropriate. Close follow up by the PM&R team should be continued in order to evaluate if return occurs after surgery. In addition, this patient will make a great inpatient rehab candidate and should be admitted as soon as the patient is medically stable.
Differential diagnoses to include: Epidural abscess, compressive tumor, aneurysm, dissection, stroke, acute disc herniation. Other possible causes of his symptoms include AIDP, and syphilis.
Italicized words = examiner response.
Check Syphilis antibodies considering sensory exam – Syphilis studies are normal.
Check CT with and without contrast to rule out compression/fracture – CT does not show fracture but does show compression of the anterior spinal cord in the lower thoracic level.
Check MRI/MRA with and without contrast to further evaluate compression lesion –  MRI/MRA with contrast further defines this as a likely aneurysm of the anterior spinal artery compressing around the T10 level. Signs of ischemia along the anterior section of the spinal cord are also present at the same level as the aneurysm.
Check EMG to evaluate acute onset lower extremity numbness and weakness – The EMG is deferred due to the above findings.
Top 5 questions to ask:
The examinee should also ask about the general exam (heart, lungs, abdomen, etc).
Vital signs:Â Within normal limits. Overweight.
Gen:Â Alert and oriented.
Cardiovascular:Â Normal
Respiratory:Â Normal
Abdomen:Â Normal
Extremities: +1 edema
Neurovascular: Cranial nerves are intact. No sensory deficits in the upper extremities. 5/5 UE strength. 0/5 throughout the bilateral lower extremities. Decreased sensation to temperature and pinprick throughout bilateral lower extremities.  Temperature and pinprick are also absent up to T10. Vibration and proprioception is intact at bilateral great toes. Unable to illicit lower extremity reflexes but upper extremity reflexes are intact. Babinski sign is present bilaterally. Hoffman’s absent bilaterally. Bilateral ankle clonus exists. Weak pulses present at bilateral dorsalis pedis’.  No low back tenderness to palpation. Anal light touch sensation is intact, but there is no voluntary contraction.
Top 5Â questions to ask:
Examinee should also ask all other questions regarding the history of present illness (ROS, PMH, Meds, etc).
HPI (continued):Â
Since that time, he has been incontinent. He denies trauma. He reports he an episode of viral gastroenteritis not long ago. He has not been around other sick contacts. He states numbness, but denies tingling or burning pain.
ROS: + constipation. All systems have been reviewed and are negative.
PMH:Â No significant past medical history. Has been admitted in the past for incision and drainage of abscesses.
PSH:Â No significant surgeries.
Family Hx: Mother and father are deceased, but were healthy.
Social Hx:Â Smokes 1 ppd and no longer drinks alcohol. Single and lives alone. He is not currently working. He is an IV drug user
Functional Hx:Â Prior independence
Medications:Â None
Allergies:Â NKDA