Things are going fairly well as I type this on January 3rd, 2024. My health decided to close out the year by reminding me I’m not getting any younger. I’ve had this intermittent vague pain and paresthesias mostly in my left arm for years. I think I may have even posted about it several years ago when I had severe elbow and forearm issues that were aggravated by playing various musical instruments. That was more bilateral, but maybe the left was worse.
Fast forward to this last year and I’ve had recurrent mild issues almost solely in the left arm, starting at the shoulder and going all the way to my fingers. It seemed to predominate in a more ulnar distribution, but the entire limb can be affected. I think prolonged less than ergonomic fixed positions at my desk probably aggravated the issue.
On Christmas Eve we decided to drink the champagne that had been reserved for New Year’s Eve and that rolled into several glasses of wine as I had a pleasant evening watching the Police reunion concert and some other music videos. On Christmas Day I was slightly hungover, but not feeling too bad. I had a decent day - did some baking (rolls, cookies, pizza), walked the dogs, and felt better as the day progressed. As of dinner time, I was feeling fine, although maybe my arm had been acting up during the day, I hadn’t noted any change.
Around 6-7 pm, the pain in the arm increased in severity and was affecting the entire limb from the shoulder down. I couldn’t find a comfortable position and was unable to sit still. I got up and walked around, tried to move the arm through various rotations, and even went outside for a few minutes despite the cold. Nothing I could do was helping and the pain was spreading to my chest and then jaw, while also increasing in severity. I’d characterize the normal pain level at an annoying 2 most of the time, but this episode started as a 6 and was climbing towards 8-9.
I think I took some Tylenol and was still unable to sit still and get comfortable. I thought I might lie down and see if I could sleep it off. That aggravated the jaw and now neck pain, and the severity kept increasing. Being a PA, I recalled from my training in ACLS that one of the instructors referred to an acute myocardial infarction as “infarcting” as opposed to infarction. Meaning, the condition progresses if no actions are taken.
I was downstairs (I think to get Tylenol, but can’t remember the exact sequence of events) when Aeyong got up to get the dogs to go outside since they can be recalcitrant when the weather’s cold or rainy. She immediately noted something was wrong and I told her I thought I might need to go to the ER. She shifted to Defcon 1 in two seconds and was donning clothes and scurrying around the house to grab her purse and keys.
She was taking it more seriously than I was, although the fact this was my first ER trip in 29 years wasn’t lost on me. I decided to go to Medical City in Arlington since it had been recommended to us when Aeyong broke her wrist a few years ago. I think that recommendation was more based on the facility being a Level 1 trauma center as opposed to the quality of the ER.
To their credit, when I presented with chest pain they got me back for evaluation within a few minutes, performing an EKG, CXR, and drawing cardiac labs. We were sent back to the waiting room pending the results. I got a look at the EKG while still in the room and it was “abnormal” based on I think t wave inversion, but there was no significant ST elevation or Q waves that I could spot. Honestly, I had a low index of suspicion for cardiac since I still run regularly and although I have some risk factors, I don’t smoke and my blood pressure has been essentially normal during routine exams.
In the ER my BP was high - 162/98, and this trend would persist during most of this episode. We waited in the ER for several hours, although I think at one point one of the nurses came out and told us the cardiac enzymes were normal. This was my main concern, and with normal enzymes, I was relatively reassured that whatever was going on, it wasn’t cardiac. They kept us for six hours or so, primarily so that serial enzymes could be run and these were also normal.
Ironically, my pain was getting worse and was now becoming more diffuse across my chest, neck, and jaw. It stayed on the left side only, never crossing the midline in the chest, but it was bilateral in the neck and jaw area. Medical City did its main job, but other than that, I was underwhelmed. I was evaluated by a PA, and to his credit, he made sure the most life-threatening issue was cleared, but he never asked about my pain level from a therapeutic standpoint, and at the time he gave us the serial results his attitude was “enzymes are normal” as if there was nothing left to discuss. He never asked about whether my symptoms had changed or worsened, and he never offered any therapy or pain management.
In his defense, I didn’t ask or press the issue because I knew the ER wasn’t my PCM and it was 3:30 in the morning and we were ready to go home. The walk out to the car was some of the worst pain I had felt all night and Aeyong was asking me to go back in or to go to some other ER. I was inclined to believe it had to be neuropathic or musculoskeletal and although quite painful, not life-threatening.
We made it home and I think I took some Tylenol while we tried to get a few hours of sleep. I got up around 7ish and was able to book a follow-up with my PCM for the next morning. Throughout the day the pain never got much better so I tried a hot shower (which helped temporarily) and continued with Tylenol. Aeyong suggested her Robaxin which I tried but didn’t notice any difference. I think it was that night that I couldn’t sleep so I took some leftover Hydrocodone from a previous dental procedure. This gave me a good 4ish hours of uninterrupted sleep.
When I saw my PCM, she was concerned that this might still represent an undiagnosed cardiac or pulmonary issue so she recommended that we go across the street to the Mansfield Methodist ER. We followed her advice and were soon whisked in and went through the same initial workup. EKG, CXR, labs. The ER doc also wanted to run some additional inflammatory markers (ESR, CRP) as well as D-Dimer and BNP. Those markers were all elevated although the cardiac exam was still normal.
She then sent me for a CT Pulmonary Angiogram within the ER to rule out pulmonary embolus and this exam was essentially normal except for some nodules (benign) and a trace pleural effusion that was unlikely to be of any clinical concern. She suggested that there could still be underlying cardiac issues that would need a Cardiologist and further diagnostic studies to rule out. She recommended hospital admission to streamline and expedite the process, stating that it could take weeks or longer if pursued as an outpatient.
I was initially hesitant since this was my first ER visit and possible hospitalization since 1994, most importantly, my first since retirement and I was concerned about cost. Aeyong was adamant that I get a thorough workup and not leave questions unanswered. To her eternal credit, she is always going to push for me to get adequate healthcare and evaluation and not leave things to chance. Despite the possibility of a financially devastating hospital bill, I took Aeyong’s and the ER doc’s recommendation and decided to go forward with the admission.
Bed space was precious, so l was admitted to a just-opened room in the OB ward. The room was quite nice, almost more like a hotel with a private bathroom, desk, recliner, couch, and bed. I was kept under observation and offered some pain relief. I tried T3 with codeine which didn’t do much to blunt the pain. The pain had essentially continued but was coming in waves of severity and then settling down for no discernible reason. It seemed to be centered in the left shoulder and at times would shoot back up to a 7 or 8. After midnight the nurse offered pain relief and I said I didn’t want T3 and would prefer just a gram of Tylenol instead. She then said I could get Hydrocodone if I wanted and I related that it had helped at home, so I decided to have it.
Again, the Hydrocodone helped me get about four hours of sleep. I was NPO as of midnight so they could perform the cardiac stress test. I should mention they had given me nitroglycerin in the ER, and I think it helped some with my chest pain, but can’t state that with confidence. The one outcome I’m relatively sure about is that it gave me a headache and this persisted through the day into the evening. In the morning my primary pain was the headache, as the shoulder and chest pain had died down somewhat.
The night before and earlier that morning I was relatively certain I would need the chemical stress test as I would be unable to perform the treadmill stress test due to my headache and other pain. Once I got down to the testing suite in Radiology, my only pain was the headache and I felt capable of at least trying the TMST. I went through with it and was able to complete the test satisfactorily.
We went back to the room and Aeyong got some food so were able to share a brunch so to speak. Periodically throughout my stay, they would check vitals (Q4h I think) and at times of rest they would be more normal, but if I was up and moving around the BP especially would get higher. Thus far, most testing was normal, except for the D-Dimer, ESR, and CRP. These were all elevated, but they’re non-specific so they mostly only raised more questions rather than providing answers.
I eventually had another radiology tech come to my room in the late afternoon to conduct an echocardiogram there at my bedside. A little after 5 my nurse came in with some papers and notified me I had been discharged by the Cardiologist/Hospitalist. They were confident my issue was non-cardiac and didn’t warrant further testing or hospitalization. I agreed with them and had to get Aeyong out of bed back home to come pick me up. She had run herself ragged going back and forth between home to care for the dogs and coming to the hospital to look after me. Her gas tank is much smaller nowadays and she can quickly drive herself to exhaustion and pain when anything disrupts the normal schedule.
I’m now nine days past the initial episode. The shoulder and arm issues persist, albeit much decreased in severity. I have a follow-up pending on Friday with my PCM, Dr. Avenesyan. My working diagnosis is neuritis or radiculitis that flared up for whatever reason and spread to adjacent structures for reasons undetermined at this point. I’ve been able to walk the dogs every day and I even was able to run on the treadmill yesterday, although a bit slower (5 mph) and for only three miles. I made some changes in my office, removing the wheels from the desk so it’s slightly lower and even putting the keyboard in my lap as I type this long-winded explanation.
I’ll see on Friday whether my PCM wants to send me for further studies. I imagine a CT or MRI and possibly a Neuro/Pain Mgmt eval might be in the cards. All this rambling to relate the conclusion that my threshold for health problems is decreasing as the years pass. I had an acute episode of foot swelling this summer that I think was brought on by excessive sodium intake (snacks) as well as alcohol consumption. I hadn’t drunk any alcohol after that episode up until Thanksgiving. That week saw my frustration with Berklee at an all-time high and accelerated my previous holiday plans by nearly a month.
This rolled into drinking beer for about three weeks straight (we went through four cases of beer in that time frame) as well as not exercising or eating particularly healthy for over two weeks. Ironically, I had returned to my normal schedule for over a week and had run on Sunday without any significant issues. I don’t necessarily think the Christmas Eve champagne and wine were the direct cause of the episode, but a repeating theme in the past few years has been that my health isn’t quite as resilient as it was in my younger days.
I can no longer negate the alcohol and unhealthy food choices with exercise. Now, I have to manage my nutrition more closely than ever before. Alcohol and junk food can manifest as poor health outcomes within just a few days as opposed to being inconsequential (in the short-term) in the past. Whenever I drink now, almost every health metric starts to suffer - sleep quality, nutrition, activity level, mood, cognitive function, motivation, etc.
I haven’t sworn off alcohol permanently, but I’m going to need to shift to small amounts over brief periods, for example, a six-pack shared with Aeyong every few months and never the larger amounts consumed over consecutive days. I’m happy that I never became an alcoholic, but it’s easy for it to become more habitual if you’re complacent about it. To bring things back to the start of this novella, complacency is no longer an option when it comes to my health.
As we age, we have to an active role in managing our health or we’ll be forced to continually rely on the aid of others as we watch our health gradually decline. I’ve set a goal for myself that I won’t have any alcohol or junk food (like Doritos) until I get my weight back under 200 pounds. I had got it down under 210 just in November, but I think I probably gained back another 5-10 pounds since then. Hopefully, once I return to regular exercise and a better diet, those pounds will start coming off. I’ve been largely ambivalent about being overweight for a long time, but I’ve got to take a more holistic view because all aspects of my life tend to take their lead from my physical health.
