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  • 76-year-old female with hypercholesterolemia, prediabetes, and various symptoms is referred for further investigations
  • PCP seeking advice on evaluating non-radiating chest discomfort, identifying the cause of chronic foot pain, and potential causes of angular cheilitis
  • Specialist recommends cardiac evaluations, X-rays and orthotics for foot pain, vitamin testing and discontinuing lip products for angular cheilitis, and possible dermatology consultation if needed

eConsult Transcript

PCP submission

The patient is a 76 year old comes in with daughter not taking any medications Labs results reveal Hypercholesterolemia and complains of mutliple complaints chest discomfort and feeling tired. She complains of dizziness on occasion and loss of vision in the left eye with blurred vision on one occasion that did not resolve until 4 hours later last month.

She has pain bilateral foot on the plantar surface. Her labs did not reveal elevated glucose but she had Prediabetes.

She also needed further evaluation of angiular chelitis on the left side of her mouth. She denies any vitamin deficiency.

Patient with Hyperlipidemia, Angular Chelitis, Vision blurred and loss of vision for few hours, and floaters seen on occasion. Referral for further evaluation with Opthalmologist, Patient needs EKG and cartoid doppler to evaluate for carotid disease and also evaluation of neuropathy vrs Osteoarthris of feet bilaterally. Chronic low back pain and knee and foot pain due to obesity and and age. She needs to have a bone density to assess for osteoporosis. Patient with Prediabetes diet, and exercise and start low dose statin and evaluate after all studies to see if need cardiologist evaluation.

1. What is the most common in 77 year old with hyperlipidemia and prediabetes. Her chest pain or discomfort, not associated with radiation or other palpitation, do need further assessment of cardiac disease.
2. Foot pain evaluation need further xrays or other studies assess why chronic pain at rest or when she bears weight , seen by podiatrist did not assess if had plantar fasicitis. referred for therapy for exercise of plantar and wear better shoes.
3. What else could be reason for angular chelitis in this patient who is not taking medication is it possible to have vitamin defiency what can be the way to best assess this.

Specialist response

Thanks for your questions. 1. This patient does need further evaluation of her chest discomfort. I would start with an EKG but would also consider a stress test as women present with atypical symptoms with cardiac disease. I would also obtain a baseline CXR. 2. Yes, I would recommend obtaining XR of the feet and wearing orthotics in her shoes. I would also make sure her monofilament test is negative and that this isn’t a neuropathy. If there is numbness or tingling, I would also check a B12 level. Have her wear tight socks or even compression stockings to see if any relief in the chronic pain. She should soak feet in warm water/bathtub daily and consider taking tylenol prn to see if she gets any relief. 3. The differential for chelitis is actually quite broad. It cam be due to a vitamin deficiency like folic acid, zinc, B6, or niacin. I would recommend checking folic acid and zinc level. However, the chelitis could be due to a product (like lipstick), frequent lip smacking or an atopic reaction (esp if other signs of atopy like dermatitis or asthma). Have the patient stop using any products on the lips and start using vaseline liberally. She can also try a low potency steroid like hydrocortisone cream 1% BID for 1-2 weeks. If no improvement, would consult dermatology. Let me know if any questions. Thank you for the consult.

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