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Case 5
A 75 year-old man with hypertension, diabetes, and coronary artery disease has severe burning, shocklike pain radiating around the right upper chest. Several months ago he had a painful, vesicular rash in the area, and was treated with acyclovir and prednisone for shingles. The rash has since resolved, but he had severe pain in the area and has been taking 15-20 or more Vicodin daily. His other medications include benazepril, glyburide, metformin, atorvastatin, ASA, and SL nitroglycerin. He used to play golf and travel extensively, but has been housebound for the past month due to pain. On
examination, light touch over the right chest just below the nipple line (“exactly where it hurts, doc!”)
evokes severe pain. His only other findings on neurologic examination are absent ankle reflexes and vibratory loss in the toes.

1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these are less likely.
3) What additional information (history, exam, laboratory or other studies, consultations) would you obtain? What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? Include doses for one medication you might prescribe, along with an estimate of the cost of a month of your proposed therapy. How would you counsel the patient about his condition and about any proposed therapy?

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