44-Year-Old Man With Shortness of Breath, Fatigue, and Paresthesia

Abstract

44-year-old man presented to the Primary Care Internal Medicine clinic with a 1-month history of shortness of breath, fatigue, and paresthesia. He reported increasing shortness of breath while stocking shelves at work and recently stopped recreational jogging because of this symptom. He also described a new, painless numbness and tingling in his fingertips bilaterally. The patient denied any history of chest pain, syn- cope, palpitations, muscle weakness, incontinence, weight changes, or recent illness. He was taking no prescription or over-the-counter medications or food supplements. He had no other relevant medical or surgical history. He had never used tobacco or illicit drugs and consumed an average of 1 alcoholic beverage per month. He had no siblings. Family history was remarkable for coronary artery disease in his father and osteoarthritis in his mother. Physical examination revealed a blood pressure of 101/58 mm Hg, with a regular pulse of 86 beats/min. The patient was afebrile, alert, and well nourished. Head and neck evaluation demonstrated a supple neck without ten- derness to palpation or carotid bruits. Scleras were normal. Neck range of motion and strength were normal. Findings on thyroid and lymph node examinations were unremark- able. Cardiac examination revealed normal first and second heart sounds without murmurs, gallops, or rubs. Lung sounds were clear. The patient's skin was pale. Abdominal examination revealed no tenderness, masses, or hepatosple- nomegaly. Cranial nerve examination revealed no abnor - malities in cranial nerves II through XII. Sensation was intact throughout, except for reduced pinpoint discrimina- tion of the bilateral finger tips. The Phalen maneuver and Tinel sign were negative. The extremities, including the th- enar musculature, were of normal tone, bulk, and strength, with symmetric and normal reflexes throughout. The lower extremities had mild varicosities but were not edematous. Babinski testing was normal. Gait testing was normal ex- cept for mild unsteadiness during the tandem walk.