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Medical Case Study: Dr. Sanchez's Case

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Dr. Sanchez refers this 30-year-old, RH, active duty Coast Guard male for evaluation of myalgias. He states he was doing well until 03/2017. Around that time he started noting achiness in his muscles in his upper and lower extremities and felt the joints were involved to a certain degree. He recalls that when he was on the Coast Guard ship, he had trouble getting out of his bunk-type bed. He was feeling weak overall. He denied any fevers. The patient had been on Lipitor at that time for almost two years, he states, for elevated lipids, which runs in his family. When he saw Dr. Sanchez, I believe in May 2017, he was taken off the Lipitor. At that time he had CK, myoglobin, RF, and TSH, which were all normal. He also had a normal neurologic exam. He was referred to my office on 05/30/2017. …show more content…

At that time he started working out again and doing what he normally would, he enjoys lifting weights. He was at sea again at the end of June until the end of August and states everything went okay, no recurrence of symptoms. Per the patient, he apparently has had elevated liver function tests, and Dr. Sanchez has been evaluating this with ultrasound and referral to GI, has not yet done the latter. He is still off statin medications. The patient tells me that before he was on Lipitor, he was on Zocor for a year or two and does not recall having any muscle aches with that. This was stopped a couple of years ago and then he was put on the Lipitor. The patient denies any history of muscle disease. He has not really noted any twitching, fasciculations. He denies any neck or back pain. MEDICAL HISTORY: Fractured ankle, right foot. SOCIAL

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