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Dr. Andrew Rynne
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Dr. Andrew Rynne

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Suggest treatment for severe pain and numbness in legs

Answered by
Dr.
Dr. Matt Wachsman

Addiction Medicine Specialist

Practicing since :1985

Answered : 3511 Questions

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Posted on Mon, 6 Jun 2016 in Pain Management
Question: An elderly woman of 72 have been having chronic severe pain on both legs. She feels numb on both limbs. Heaviness is also experience upon sitting, walking or even lying down. Sometimes the pain worsens upon ambulation and relieves a little bit when resting. Feeling of dizziness and headache are part of the verbalized symptoms.

Pt has arthritis, diverticulitis, cataract, chronic pain, GERD. Colonoscopy, mammogram and bone densitiometry done about 2 years ago, and all the mentioned tests came negative (though the diverticular was found during the colonoscopy).

Pt is always taking analgesics (NSAIDs). Presently did a blood test and malaria parasite and typhoid were found. Became constipated after certain doses of the anti malaria drugs. Lost appetite and felt nauseated. Laxative was given and pt had profuse diarrhea. Pt became so weak and unable to ambulate. Diarrhea has ceased, anti malarial treatment and treatment for typhoid has continue. IV infusion was given in addition to ORT that was continuously given during the diarrheal episodes. Ambulating now with assist of 1 person, but pain is still excruciating and soles of feet feel 'foamy' on ambulation. Pt is currently taking sodium naproxen twice a day. Pt is also on B-complex multivitamin in addition to the anti malaria medication and that for typhoid. Oh a little blood was found in urine that was recently done and pt has UTI now. Hot compress has continually been administered on both limbs.
Pt had 9 kids and has been widowed since 1993. Pt did a lot of manual and physically engaging jobs to help raise kids.
What treatments can you suggest that help get the pain curbed and get those limbs agile again?
doctor
Answered by Dr. Matt Wachsman 2 hours later
Brief Answer:
An unique question

Detailed Answer:
First, the point of view of the question is unique. Ive never had one that was both NOT first person NOR identified the relationship between the speaker and the subject. In this context, I am technically not allowed to comment on the person. So, I wont.

This then is a general information exchange about muscle pain, not about any particular patient that I have not examined and certainly not about a particular patient who has not given any consent for transfer of information.

Muscle pain can be readily identified as the source of the pain (as opposed to joint, tendon or nerve origen) by it being elicited by muscular activity or poking the muscle(s). The (s) is critical at differentiating a process affecting a particular muscle (bruise) and a systemic effect on muscles (everything that goes into a muscle being able to move). Anything affecting muscle activity can be perceived as painful. Here they are in the order of addressing them.
Energy metabolism. This should be addressed first because it can be rapidly fatal if it is not. Sufficient nutrients and food. This especially involves thiamine, folic acid, then glucose oops.... before all of that phosphorus. Probably a rapidly and completely absorbed combination of glucose, potassium, phosphate with a bicarbinate buffer should be given after administering thiamine intramuscularly. The formulation of nutrients can be given orally BUT should be certain to be sterile. Oh, wait, here is some, it has the brand name COCA COLA. (Im quite serious on this, it is the preferred method for giving phosphate to those recovering from starvation at University of Maryland and has potassium phosphate, sugar and bicarbonate).
Then, repletion of other electrolytes, potassium might be already taken care of but magnesium and calcium. Calcium levels can be rapidly assessed by checking tendon reflexes if they are too active the calcium (or magnesium and secondarily the calcium) is too low and simple supplementation is necessary.
Energy, vitamins, minerals, protein...oh... protein is quite a problem...
Because the muscle ache associated with a systemic inflammation is muscle protein being broken down in a prostaglandin and inflammation dependent series of events. While anti inflammatories such as naproxen are helpful, you have to stop the underlying conditions (like malaria, typhoid, etc.). And there can be secondary infections such as CLOSTRIDIUM DIFICILE from antibiotics or UTI or others. Parasitic infection is really common even in the first world and is generally missed. So, you are not going to overcome the ache until the underlying conditions are fixed.

Next is assessment of the muscle protein/health itself by measuring creatine kinase if it is elevated the muscles are breaking down. This has to be fixed or there will continue to be pain.

We have covered the muscle protein, electrolytes, hydration, minerals, vitamins and energy supply. Next is the physiology external to the muscle that is important. Oxygen and nutrient flow. Fatigue is a sign of muscles not getting enough external oxygen and nutrient flow. This is due to blood flow. In the first world this is generally due to poor circulation due to atherosclerotic disease. this is always lower extremities and never all four extremities. In the third world it is more commonly due to low blood count/anemia/low blood pressure. This is all over and associated with overall fatigue and dizziness or fainting or malaise. It can be easily tested for. It may not be so easily corrected if due to malaria or typhoid or hemorrhagic fevers. Mostly, waiting them out. Perhaps transfusion, perhaps iron supplementation but all of these are complicated by a lot of individual factors. Finally oxygen flow due to lung disease can be an issue and would have signs of low oxygenation if that is measured.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Matt Wachsman 2 hours later
Thank you doctor for your responses.

I understood you are of the suggestion that underlying issues be dealt with first. Since she had been treated for malaria, typhoid and UTI, retests have to be done to ascertain the effectiveness of the anti malarial, anti typhoid medications and that for UTI that were administered. Then those other listed tests (stool tests for parasite and clostridium difficile, complete blood counts, hemorrhagic fever, creatine kinase will be done too.

Is the coca cola you mentioned for sourcing phosphate the soda drink? So can she get any protein supplement? She is really having difficulty eating. Her current blood pressure reading is 117/54, and a recheck read 108/52. Prior to her current health statuses she BP had been within normal range.

What foods will help to promote her oxygen and nutrient circulation to her entire body. Since she has been having difficulty eating, can nutrient supplements like ensure be good for her. And can energy drinks be gone for her? How about any protein drinks? Can she continue with her anti inflammatory medication she has been taking twice daily?

Currently feeling thirsty regularly. She still has edema on both limbs. And still feels a heavy object is placed on her. She is drinking in bits now. She is being assisted to sit up or lay down.
doctor
Answered by Dr. Matt Wachsman 2 hours later
Brief Answer:
wouldnt know for an individual patient.

Detailed Answer:
Coca cola is indeed, the soda. It really is very good for phosphate depletion.
Protein is protein. Meat is a complete protein, but the exercise/muscle building literature shows that most any protein can work (beans by themselves might not be the best since they do not have all the amino acids found in muscle in the right proportions; whey protein is pretty good by itself and certainly the two together are find) BUT questions of 1) gut absorption 2) how much someone can eat due to other conditions and 3) inflammation makes the body tear down muscle and not build it up are particular to particular individuals and this trumps general input about protein dynamics. Its mainly the protein source the person will take in; personally it is brisket squares covered with every sauce packet in the refrigerator mixed 1:1 with sugar and then slow roasted until carmelized in a 245F degree oven.

Which brings up food for oxygenation. 1) someone has to have enough red cells to be able to carry oxygen...so iron containing foods (the brisket) 2) perhaps increased salt and fluid intake (yeah, the brisket), and third, and this isnt that important, some foods use up more oxygen in digestion and storage than others so IV nutrition for COPD patients used to include a higher fat content (yup, the brisket wins again). Then, it is what can be taken in easily. Small amounts, finger food, dense in nutrition and tender and not requiring a lot of chewing (well, MY brisket certainly is all of the above, but that varies).

Edema states are worrisome. Salt and fluid intake is generally recommended to be limited (sorry, brisket). This can occur from heart, lung, kidney, or liver failure OR due to serious thiamine deficiency (fixable by ONE injection of thiamine!) But it is most common to occur from just low protein. This occurs with age, debilitation, inflammation, and not taking in protein. It is very hard to fix; frankly the heart failure or lung failure are more easily treated.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Matt Wachsman 1 hour later
Dr XXXXXXX how often should the thiamine (Vitamin B1) injection be administered?

If she is given adequate iron-containing foods (assuming that her appetite improves), is the iron supplements indicated here still? And should there be preference to wheather her the iron supplements should be liquid or tablets?

Is the folic acid going to a tablet that will be given orally, and what is the dosage and for how long will it be taken? If salt and water intake are contraindicated in edema and indicated in oxygenating the body (alongside consuming iron-rich diets or taking iron supplements), how can a balance be stricken in the amount of salt and water this patient takes?
doctor
Answered by Dr. Matt Wachsman 3 hours later
Brief Answer:
several points

Detailed Answer:
Thiamine is given intramuscularly and has to be done by a physician. Folic acid is given as 1 milligram a day.

Otherwise most of the questions are patient specific based on parameters I wouldn't have (iron supplements are only if someone has low iron. Edema comes from different states. Low blood pressure can be from dehydration and need fluid and salt. In all patients balance of fluid state has to be assessed about daily and different medications given based upon specific clinical situations (liver failure and edema, you'd let there be some edema and give fluid and salt enough to keep everything running. Heart failure you might also if it is only ONE side of the heart and fluid NOT going into the lung). It depends.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Matt Wachsman 32 hours later
numbness of limbs, edema, unintentional tremors observed, unable to ambulate has persisted. Doesn't that B1 come in liquid form?

Had a violently stroke-like episodes for almost an hour. Have difficulty getting food down the throat, so she barely eats. Diastolic BP in the 50s in repeated attempts (108/55, 101/52,...). Burning or uneasy feeling on the throat.

Lost ability to verbalize after the violent shaky moments. Talking now. Lost orientation to place (asked "where are we now"). Exhibited episodes of confusion. Being assisted to change positions. Ability to use limbs that got compromised is still in persistence at the moment. Takes B-complex had been administered all these while. A mixture of malt drink and milk is another thing that she manages to get down. Did not sleep the night before the episode occurred. Could not sleep last night either (slept a bit but had repeated "get me up, put me back to bed" moments.


Pt was being treated with alternative medicine for strong belief system that stroke-like signs and symptoms are better handled with alternative medicines and herbs.

But a rethink is gaining ground for a profession medical teams now that it has taken this route.
doctor
Answered by Dr. Matt Wachsman 4 hours later
Brief Answer:
Thiamine is in regular vitamins

Detailed Answer:
but you would never give it that way in someone who may have either severe malnutrition and/or poor gut function.

without an exam, I can only give general information but serious symptoms such as near stroke, malnutrition with metabolic problems would be reasons for emergency hospitalization and a lot of tests such as visualization of the head, evaluation of protein, iron, electrolyte levels. Probably iv total nutrition and evaluation of gut function.

which ...basically closes the discussion.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Matt Wachsman 47 hours later
Honorable Dr XXXXXXX

I know you kind of got ur discussion to the apex, but I would so value that you comment on the current situation shown below:

Pt has just been hospitalized.
Redone laboratory test status are:
1. Blood reduced from 75 percent (previous reading) to 45 percent
2. Ulcer
3. Malaria 3+
4. Typhoid (more than previous lab test)
5. Worm found
6. Blood found in urine
7. Hepatitis

Should there be any alterations to your earlier suggested treatment prioritization? Which treatments should come before the others and which ones should be concurrent? Which other tests and laboratories should be done?

I humbly plead for your speedy response. Thank you doc!
doctor
Answered by Dr. Matt Wachsman 31 minutes later
Brief Answer:
kind of what I said

Detailed Answer:
except what is ... *blood*? perhaps amount of ? so ... severe anemia as I did expect and that can be a cause of heart failure and lack of oxygenation to organs as I said.

And at least 2 if not more infections which would be the first thing to treat to overcome inflammation....

No, thats kind of where I was going with this.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Matt Wachsman 4 hours later
She is was catherized. She was receiving blood transfusion. But she started having a very "violent-shaky" reactions like the one she experienced on Tuesday.
doctor
Answered by Dr. Matt Wachsman 2 hours later
Brief Answer:
so many possibilites !

Detailed Answer:
Shaking chills are part of malaria. They often are part of typhoid. The reason behind typhoid is the same as one of the more common transfusion adverse effects causing shaking: release of a bacterial coating that causes immune reactivity. Endotoxin can be in blood that isnt even contaminated with bacteria. It will produce shaking chills.
Then there can also be low potasiium or magnesium or other electrolyte imbalances that can cause shaking. For that matter if there is enough transfusions and the person is small, one of the blood preservatives (EDTA) binds up the calcium in the blood and the person has a reaction to the low calcium (increased muscle tone that can also cause shakes and chills). There can be otehrr infections causing fever and shakes and chills Epilepsy if it caused all over shakes would have to also cause unconsciousness.

Cannot say in her particular case but if someone had a symptom already there before a transfusion, then it probably is NOT the transfusion. Malaria is well known to cause shakes.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Matt Wachsman 14 hours later
Thank you Sir. She was given some medication that took care of those reactions. She is on more IV infusions. But she continued to experience difficulty swallowing or getting things down the throat, even water.

She had a reasonable quantity of custard with milk yesterday. And since that seems to be that tolerable so far, that will be a priority meal option at the moment.

It is reported she could talk and communicate with high degree of sensibility and at length now. Compromise of limb functions has not changed. Edema is somewhat reducing. Pt is assisted with all activities of daily living, feeding inclusive.
doctor
Answered by Dr. Matt Wachsman 4 hours later
Brief Answer:
Obviously I can only give general information.

Detailed Answer:
There is a considerable amount of weakness associated with multiple infections in the elderly. This can make eating and drinking and other activities limited just by the physical effort. While there can be a blockage of the throat that impedes food and water going down, it would have to be a near total blockage and weakness is certainly known ot be present. Improving signs of fluid/cardiovascular/overall strength are good.
Dont forget the coca cola and thiamine.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Matt Wachsman 17 hours later
Thank you so much doctor.

She has been given:
antacid liquid
cipro caplet
Blood cap,
Flaggly 2 tabs
Colf syrup
Analgesic

Pain reported of reducing. Forgettfulness or not recognizing people still lingered.
Edema has reduced (left leg a bit more edematous). Limbs still weak. A bit Jerky movements observed on lower limbs. Pains reported on both lower limbs. Feeling thirsty and urge to drink while receiving IV infusion.

doctor
Answered by Dr. Matt Wachsman 6 hours later
Brief Answer:
You are quite welcome

Detailed Answer:
Feel free to contact me again with a directed question if you have more questions.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Matt Wachsman 3 hours later
Good afternoon Dr. XXXXXXX
The doctor says pt would meet her thiamine needs from the vitamin B-complex she is receiving. But how effective or therapeutic could that be when her limb functions are still in utter compromise statuses? Her memory is not as intact as it used to be.
And she exhibits some degrees of disorientation still.

Edema is downgrading at a snaily rate. Pt has been constipated for 3 days now. Liver seems to be tender and enlarged. What could you suggest here, Sir?
doctor
Answered by Dr. Matt Wachsman 28 minutes later
Brief Answer:
as mentioned, I am not there.

Detailed Answer:
This then is a general information exchange about muscle pain, not about any particular patient that I have not examined and certainly not about a particular patient who has not given any consent for transfer of information.

========================================
Edema states are worrisome. Salt and fluid intake is generally recommended to be limited (sorry, brisket). This can occur from heart, lung, kidney, or liver failure OR due to serious thiamine deficiency (fixable by ONE injection of thiamine!)

Thiamine is in regular vitamins

Detailed Answer:
but you would never give it that way in someone who may have either severe malnutrition and/or poor gut function.

no more edema state.

========================================
Liver can be examined by ultrasound and liver enzymes are likely already being checked. They will be elevated with malaria and typhoid. Liver failure can be indicated by lack of ability to clear bilirubin and/or inability to make proteins and clotting factors.

3 days may or may not be unusual and the overall gut function and motility has to be examined to make any conclusion.


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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