Report

 

 

NHS No: 4109147239
MRN:10638857

Nos 1 to 13 per me telling him.

1. Thank you for coming to the rheumatology clinic in Oxford today. Your GP had referred you because of
   worsening of coldness in your feet and also your hands. 
2.  
3. The symptoms have been present for about 20
   years but getting worse. You observe a feeling of coldness without any noticeable colour change in
   either hands or feet. 
4.  
5. The feeling of coldness may occur in cold weather but can also be present when you are in bed at night and can wake you from sleep. 
6.  
7. You tend to have to get up and distract yourself for the feeling to become less intense. The symptoms can last an hour or so. 
8.  
9. You are not left with any discoloured areas on your fingers or toes. You have varicose veins, worse on the right leg than your left leg. 
10.  
11. You are currently also struggling with other musculoskeletal problems including back pain and recovering from your left knee replacement 8 months ago. 
12.  
13. You are starting to experience similar symptoms that you had in your left knee in your right knee. 
14.  
15. On examination you had excellent peripheral pulses and good capillary return in all 4 limbs and there was no evidence of nail edge infarcts or pulp loss. 
16.  
17. Skin texture was normal. Your pulse rate is very low at 55 bpm and I thought I could hear a mitral valve murmur. You think you had previously been noted to have heart murmur.  [[[ Should have said it was definite. ]]]
    
18.  
19. Your blood pressure was low at 101/58. You have tried vasodilator treatment with nifedipine for your cold feet but this did not help and you had a lot of side-effects. You stopped taking the drug. 
20.  
21. In summary you have have peripheral vasospasm rather than Raynaud's phenomenon. 
22.  
23. You were a smoker up until your mid 20s but I do not think that is likely to account for your symptoms. 
24.  
25. You deny any symptoms of claudication to suggest peripheral vascular disease. 
26.  
27. I was surprised at how slow your heart rate was and I think it is important that we measure your thyroid function which could account for some of your symptoms if it is found to be low.  Going to hospital for check-up 3 in weeks
    
28.  
29. I have also checked your blood chemistry and liver function. 
30.  
31. We performed an ECG in the clinic which shows you have a normal heart rhythm although it is slow at 55 beats/min. ln view of the murmur I have ordered an echocardiogram. No news yet.
    
32.  
33. I have suggested that you might try some topical GTN ointment which only is available as a rectal ointment at present. I prescribed some to be used sparingly between your toe webs for symptom relief. [[[ of no use  ]]]
    
34.  
35. ln view of your low systolic blood pressure I do not think it would be possible to give you a tablet vasodilator. [ See 19 ]  Otherwise you would feel very dizzy and risk falling. 
36.  
37. I will write again with the results of your blood tests and have discharged you back to the care of your GP.

 

Kind regards

Professor Raashid Luqmani DM FRCP FRCPE
Professor of Rheumatology
GMC Number 2578176
Rheumatology Department

Drug therapy
Citalopram
Omeprazole
Chlorpheniramine
Topical GTN ointment (Rectogesic 0.4%) to be applied sparingly to toe webs up to 3 times a day   [[  No use - see 34 ]]

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