Trevor Dubay was in to see me during a very busy afternoon session on December 22nd. I hadn’t seen him for almost a year. Last time I saw him he had come in with indigestion and acid reflux and the medication I had prescribed for him must have worked. He had called in for refills 3 and 9 months after his office visit.
This time he was in my schedule with a concern about heel pain. “Plantar fasciitis”, I figured before I knocked on the exam room door.
“Hi there. I haven’t seen you in a while. How’s the heartburn?” I asked.
“Doing good, as long as I take my pills, but I can’t go without them very long.”
“Any trouble swallowing, cough, hoarseness or belly pain?”
“No, not at all.”
“Then, in your age bracket, as long as the pills work, we’d just tell you to keep taking them. Then, maybe at 50, we’d send you for a scope test. Now, today you’re here for some heel pain?”
Sure enough, he had the typical heel pain when he first started walking in the morning and he was worse those days at work when he had to do a lot of walking on concrete floors. His physical exam was consistent with the diagnosis, so I started explaining the mechanism behind his condition and the various things we can do for it – anti-inflammatory medication, ice, stretches, heel cups inside his work boots, ultrasound treatments and, the last resort, steroid injections.
I went to pick up my handout for plantar fasciitis and heel spurs and he agreed to a physical therapy referral. I entered the request into the electronic medical record.
“Why do my hands go numb at night?” he asked when I had finished typing.
“Both hands, all fingers?” I asked.
“Uh-um”, he nodded.
“Ever happen during the day?”
“Once in a while.”
“Any neck pain?”
“No.”
“Show me how far you can turn your neck each way.”
His range of motion was normal, as was the strength in his arms and hands. He had normal feeling in all fingers. Tinel’s and Phalen’s signs were negative – no sign of carpal tunnel syndrome – and Adson’s maneuver was negative – no sign of cervical ribs or any other impingement of the circulation to his arms. He did wince slightly as I pulled his right arm back, though.
“My shoulder’s been sore for years”, he explained.
“That wouldn’t explain both hands tingling, though”, I said. “I don’t think you have carpal tunnel syndrome, and it doesn’t look like a clear cut neck problem, although sometimes too thick a pillow can trigger this sort of thing. I think you have what we call acroparesthesias…”
“What do you think of this rash?” he interrupted, and exposed his neck and upper torso.
“That’s called Tinea Versicolor. It’s an infection that changes how the pigment in your skin behaves, We treat it with athlete’s foot creams, but then you have to tan a little to even out the color sometimes.”
“Oh, I can buy one of those creams over the counter, right?”
“Sure, any one of them. Leave it on for a good ten minutes, then wash it off. Do that once a day for a week.”
“Great.”
“So, for your heels, you’ve got the exercises, you can get the heel inserts, buy some naproxen. They’ll call you from physical therapy for an appointment. And – if all else fails – we can give you a shot.”
He winced.
“So, you and Beth have a good Christmas”, I said as I got up from my stool and reached my hand out towards him.
“You too, but what about my shoulder?”
I paused and glanced at the time; 22 minutes into his scheduled 15 minute visit.
“Well, that’s a whole other project. We’ve covered a lot of ground today already, and my next patient is waiting. We could order an x-ray and have you come back for a full evaluation of your shoulder if you’d like.”
“Never mind”, he said.
A Country Doctor Writes: 
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