Patient Information:
Name: Mr. Ahmed Ali
Age: 45
Gender: Male
Occupation: Construction Worker
Socioeconomic Status: Lower middle class
Presenting Complaints:
Mr. Ali presents with complaints of sharp, shooting pain in his right heel, exacerbated by weight-bearing activities such as walking and standing. He reports experiencing tingling and numbness in the same area.
History of Presenting Complaints:
The patient reports that his symptoms started approximately six months ago without any specific injury. Initially, the pain was mild and intermittent, but it has progressively worsened over time, affecting his ability to perform his job and daily activities.
Chief Complaints:
Mr. Ali’s chief complaints are severe pain and discomfort in his right heel, significantly impacting his mobility and quality of life.
Past Medical and Surgical History:
No significant past medical history
No history of surgical procedures
Family History:
Non-contributory
Present and Pre-morbid Functional Status:
Prior to the onset of symptoms, Mr. Ali was fully functional and active in his occupation as a construction worker. However, the current symptoms have severely limited his ability to work and engage in daily activities.
General Health Status:
Overall, Mr. Ali’s general health status is fair, aside from the debilitating symptoms affecting his heel.
Vitals:
Blood pressure: 130/80 mmHg
Heart rate: 78 bpm
Respiratory rate: 16 bpm
Temperature: 98.6°F
Aggravating Factors:
Weight-bearing activities such as walking and standing exacerbate the pain.
Easing Factors:
Rest and elevation of the affected foot alleviate the symptoms temporarily.
Examination:
Inspection: No visible signs of trauma or inflammation. Mild swelling noted around the right heel area.
Palpation: Tenderness elicited upon palpation of the medial and lateral aspects of the right heel.
Sensory Examination: Reduced sensation noted in the distribution of the first branch of the lateral plantar nerve.
Range of Motion: Limited dorsiflexion and plantarflexion of the right ankle due to pain.
Sleep and 24-hour Pattern:
The patient reports disturbances in sleep due to nocturnal pain in the affected heel.
Duration of Current Symptoms:
Symptoms have been present for approximately six months, progressively worsening over time.
Mechanism of Injury/Current Symptoms:
No specific injury reported. Symptoms started gradually without any identifiable trigger.
Progression Since the Current Episode:
Symptoms have progressively worsened, significantly impacting the patient’s daily activities and quality of life.
Significant Prior History:
No significant prior medical history related to neuropathic conditions.
Previous Treatment:
The patient has tried over-the-counter pain medications and topical analgesics for symptom relief with minimal improvement.
Diagnostic Test/Imaging:
X-ray of the right foot: No significant abnormalities noted.
Electromyography (EMG) and nerve conduction studies (NCS): Pending for further evaluation of nerve function.
Differential Diagnosis:
Baxter’s Neuropathy
Plantar Fasciitis
Tarsal Tunnel Syndrome
Calcaneal Stress Fracture
Postural Observation:
Mild pes planus (flat feet) noted on postural observation.
Precaution and Contraindications:
Avoidance of activities that exacerbate symptoms, such as prolonged standing or walking.
Functional Movement Analysis (Sign):
Antalgic gait observed due to pain in the right heel.
Quick Screening Tests/Clearing of Additional Joint Structures:
Negative for additional joint involvement or referred pain from adjacent structures.
Range of Motion (ROM):
Limited dorsiflexion and plantarflexion of the right ankle due to pain.
Special Tests:
Tinel’s sign over the tarsal tunnel: Positive
Compression test over the first branch of the lateral plantar nerve: Positive
Assessment:
Based on clinical findings and history, the diagnosis of Baxter’s Neuropathy is suspected.
Problem List/Complaints:
Severe pain and discomfort in the right heel
Tingling and numbness in the heel region
Limited mobility and functional impairment
Treatment:
Conservative management including rest, activity modification, orthotic devices, and physical therapy.
Consideration for corticosteroid injections or surgical decompression if symptoms persist despite conservative measures.
Prognosis:
With appropriate management, the prognosis for Baxter’s Neuropathy is favorable, and significant improvement in symptoms can be expected.
Goals:
Alleviate pain and discomfort in the right heel
Improve mobility and functional status
Prevent recurrence of symptoms
Interventions:
Initiation of physical therapy for stretching and strengthening exercises
Prescription of orthotic devices for support and offloading of the affected heel
Patient Education:
Educate the patient on activity modification and the importance of compliance with treatment recommendations.
Provide instructions on home exercises and self-management strategies.
Patient/Family Education:
Discuss the nature of Baxter’s Neuropathy and its expected course of treatment.
Address any concerns or questions regarding the condition and management plan.
Discharge Plan:
Follow-up appointments for monitoring of symptoms and response to treatment.
Referral to a specialist for further evaluation if necessary.
Provision of contact information for any urgent concerns or questions.