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A Middle-Aged Man With Painful Dysesthesias in the Lower Limbs

A Middle-Aged Man With Painful Dysesthesias in the Lower Limbs

A 58-year-old man presents as a new patient. He is generally well but has been concerned for about 4 months about some tingling, numbness, and mild burning in his lower legs. He denies any history of leg problems. There is no back pain, muscle weakness, bowel or bladder changes, and no symptoms in his upper extremities. He denies any visual changes, dizziness, weakness, fatigue, chest pain, shortness of breath, or abdominal discomfort. He does not smoke and drinks alcohol socially.

The patient has had hypertension for 15 years and his triglyceride level is high. His medications include lisinopril, 20 mg/d; hydrochlorothiazide, 25 mg/d; and fenofibrate, 145 mg/d.

Laboratory results from 18 months ago include normal values for CBC count and electrolytes; BUN, 16 mg/dL; creatinine, 1.6 mg/dL; fasting glucose, 102 mg/dL. Total cholesterol, 185 mg/dL; LDL-C, 110 mg/dL; triglycerides, 180 mg/dL; and HDL-C, 39 mg/dL. Results of liver function tests and urinanalysis are normal; his ECG is unremarkable.

He is 5 ft 7 in tall and weighs 192 lb. His BP is 132/75 mm Hg, pulse is 74/min, and respiratory rate is 16/min. His waist measurement is 40 in. His HEENT examination is normal. There are no bruits, lymphadenopathy, or thyromegaly. Findings from the heart, lung, and abdominal examinations are normal. His back is not tender; rectal examination shows normal tone; extremities have no rashes or edema. Neurologic examination finds decreased sensation bilaterally below the knees. Muscle strength is normal but his ankle jerks are decreased while other reflexes are equal and normal.

Are there any red flags in the history, physical examination, or labs that concern you?

Which of the following would best help you evaluate the patient? (Please choose one)

A. Electromyogram (EMG)

B. MRI study of brain and spine

C. Vitamin B12 level

D. Fasting and 2-hour postprandial glucose levels

E. Additional alcohol history from the family



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