A 42 yo F with no known PMH presents with dry eyes.

Questions to Ask

  • Duration? Symptom severity?
  • Other exocrine gland symptoms: Dry mouth, parotid or salivary gland enlargement
  • Any arthritis, Raynaud’s, rashes or other concerning symptoms?
  • Use of contacts?
  • Any smoking history?
  • Contributing medications
  • Infectious risk factors

Clinical Presentation & History

  • Dry eyes for the past 2 years
    • Describes a gritty, burning sensation
    • No longer able to wear her contacts
  • Mild dry mouth, no parotid gland swelling
  • Diffuse myalgia and arthralgia, no swelling
  • Medications: multivitamin
  • Social History:
    • Married
    • Drinks coffee daily
    • No alcohol or smoking

Diagnostic Workup

  • Recommended labs:
    • CBC with diff, CMP, CRP, ESR
    • Testing for HBV, HCV, HIV
    • SSA, SSB, RF, ANA
    • Look for any secondary causes of sicca

Referrals

  • For rheumatology serology abnormality, refer to rheumatology
  • Refer to ophthalmology for objective testing (e.g. Schirmer test or ocular surface staining)

Treatment & Management

  • Recommend over-the-counter artificial tears for dry eyes
  • For mild dry mouth, try over-the-counter saliva substitute
  • Counsel on limiting coffee consumption and increasing hydration

A 66 yo M with PMH of hypertension reports progressive numbness and tingling in both feet.

Questions to Ask

  • Any comorbidities that cause neuropathy: diabetes, vitamin B12 deficiency, hypothyroid or other?
  • Social history: history of alcohol abuse, vegan/vegetarian?
  • Infectious risk factors: neurosyphilis, Lyme or other?

Clinical Presentation & History

  • Distal tingling, numbness present for 1 year 
  • Started in toes and progressed to mid shin
  • Worse with activity, pain limiting activity 
  • Noticed fingers turn purple/white with cold
  • No ulcerations, rashes, skin changes
  • Minimal dry mouth and mild dry eyes with gritty sensation in morning
  • No history of diabetes, no dietary restrictions
  • Social history: Denies alcohol, married, sexually active 1 partner

Diagnostic Workup

  • Recommended labs:
    • CBC with diff, CMP, TSH, HgA1c, vitamin b12, SPEP, ANA, Ssa, SSb
    • Hepatitis C/HIV if not up-to-date
    • Lyme, syphilis if any risk factors 

Referrals

  • Referral to rheumatology given late onset Raynaud’s even if serologies are unrevealing
  • If no clear etiology found based on labs, refer for NCV/EMG and to neurology.
    • If NCV/EMG neg, consider small fiber neuropathy evaluation

Treatment & Management

  • Replete any vitamin deficiencies
  • Treat any contributing comorbidities
  • Symptomatic treatment with gabapentin or pregabalin
  • Ensure up-to-date with age appropriate malignancy screening