s******t
发帖数: 579 | 1 (The patient was admitted because of MDD secondary to her debilitating LLE weakness, numbness and tightness. I'd like to focus on her neurological symptoms.)
CC:
A 72 y/o white F complains of LLE weakness, numbness and tightness.
HPI:
Pt was diagnosed lumbar spondylosis, lumbar spinal stenosis, low back pain and lumbar radiculopathy 2 yrs ago. Had a lumbar fusion 1 yr ago. Started to recover at the beginning, but had worsening of weakness and eventually required a hardware removal 6 months ago. Her weakness and numbness in her LLE still progress. She complains of difficulty going upstairs because of the weakness in her LLE. She also c/o worsening tightness, weakness and numbness in her LLE and the sensory loss went up gradually from her ankle level to knee level now. She complains that it is extremely difficult for her to do cycling like movement, and physical therapy and exercise make her symptoms particularly the tightness in her LLE worse. She complains newly happened burning sensation over the anterior of her left thigh. Pt denies fever, chills; no known systemic infections at this time.
SH: Denies h/o IV drug use
FH: non-contributable
PSH: non-contributable
PMH: HTN, SVT/a-fib
PE:
• VS: WNL during her hospital stay
• NEUROLOGICAL EXAM:
1. CN 1-XII: WNL
2. Sensation of lower extremities: LLE: decreased sensitivity to light touch, vibration and pinprick over L4, L5, and S1 distributions in her LLE, from the knee down to her foot, and worse on the lower 2/3 area with exception of the middle areas of dorsal and plantar. RLE: decreased sensitivity to light touch in the foot and up to ankle area.
3. Muscle tone of lower extremities: WNL
4. Muscle strength of lower extremity: slightly decreased L knee extension and L hip flexion.
5. Reflex of lower extremities: L knee reflex 0/4, B/L ankle reflex 0/4, normal plantar response B/L.
6. Coordination: WNL
7. Romberg best: WNL
8. Gait testing: normal cadence and step length, but some scissoring without crossover
LABS:
UA, Vit B12, folate, phosphate, magnesium, TSH, ESR, CBC w/ diff – WNL
SYPHILIS Trep Test: negative
CMP: Glu 144, Calcium 10.6, decreased Eosinophil (% and absolute number)
IMAGINE:
MRI T- and L-spine w and w/o contrast:
1. Thoracic spine: focal finding in the T10 vertebral body consistent with hemangioma.
2. Lumbar spine: there is a circumscribed paraspinal fluid collection on the left which extends from the L3 vertebral body inferiorly to S1 with enhancing rim status post fusion of L3-L4 through L5-S1 and laminectomies. There is minimal central canal stenosis at L1-L2 level, mild to moderate bilateral neuroforaminal stenosis at L1-L2 and L2-L3, and moderate to severe bilateral neuroforaminal stenosis at L4-L5 and L5-S1.
The DDx includes a postsurgical pseudomeningocele although no definite connection with the thecal sac is identified. In the proper clinical setting, this could also represent a paraspinal abscess.
1. What is the DDx? Paraspinal abscess is less likely but we will keep watching it. I am not sure what the tightness means. The muscle tone is normal though, and the results of her EMG and nerve conduction study are pending.
2. The T- and L-spine MRI was suggested to be repeated in 4-6 weeks. I will suggest C-spine MRI to them and not sure if they will do it.
Also, I will suggest them to repeat CMP and add HbA1c (thanks to A++)
I don’t know if they will listen to me if I ask them to hold her PT. Could you help me to convince them?
What else should we do? The neurosurgeon suggested us do nothing but watching at this point.
3. We have to do regular neuro exam to monitor any change. What part of neruo exam do you think is the most important and need to be done carefully? What other neuro exam should also be done?
4. Actually the result of a neurosurgen’s neuro exam is different: reflexes 2+ and symmetric. I don’t know why what he found is so different from mine. A resident’s finding is similar with mine. What do you think is the reason of the discrepancy?
5. Any problem in my case report please?
Thanks! | A*******s
发帖数: 9638 | 2 She likely has failed back surgery syndrome.
DDx: 1. Cervical stenosis.
2. DM amyotrophy
Rec:
1. MRI of C-spine.
2. EMG/NCV.
3. HgA1c. I guess elevated Glu is not fasting.
4. Hold PT. | s******t
发帖数: 579 | 3 Why cervical but not lumbar? Thanks. | A*******s
发帖数: 9638 | 4 You asked for DDx.
I assume the patient already had the lumbar MRI.
【在 s******t 的大作中提到】
: Why cervical but not lumbar? Thanks.
| s******t
发帖数: 579 | 5 Thanks. I'd like to know that what make you think about cervical stenosis.
She does not have neurological deficit in her upper extremities.
【在 A*******s 的大作中提到】
: You asked for DDx.
: I assume the patient already had the lumbar MRI.
| A*******s
发帖数: 9638 | 6 Cervical myelopathy is the most common missed diagnosis because of its
uncertain presentation. UEs sparing does not spare the cervial myelopathy.
Missed diagnosis could end up with permanent disability.
【在 s******t 的大作中提到】
: Thanks. I'd like to know that what make you think about cervical stenosis.
: She does not have neurological deficit in her upper extremities.
| s******t
发帖数: 579 | 7 Thank you A++! I updated it a little, would you take a 2nd look at it? | A*******s
发帖数: 9638 | 8 I noticed there are some changes. Thanks for the updates.
For a case like that, you have to make sure if the patient has true weakness
. In some cases, the patient could not walk or feel weak just because of
PAIN. I haven't noticed you mentioned the pain which I believe she has.
I would check ERS/CRP and CK, a lot of cases like that, especially an aged
woman, could have PMR.
DM amyotrophy is another DDx if PMR can be R/O.
With both sensory/motor involvement on a single leg, radiculopathy is more
likely. But if no reasonable explaination for her problems, UMN lesion has
to be considered since it could be a treatable condition. DTR could be nil
due to DM so it makes no difference to me who is right between you and NSG.
I don't know if you remember a case I mentioned before: Don't trust CT if
you suspect a cervical stenosis. | s******t
发帖数: 579 | 9 多谢A＋＋的详细耐心的回答！
在psych unit，他们倾向于将病人的躯体症状归罪于精神因素，我提了CK，和再测一次
BMP或CMP，但是他们不想测。更别提会测cervical MRI了。他们一直想push病人多做PT。
不过你是对的，第一次测glucose的时候病人不是fasting的，病人也没有DM 的病史。
不过，再测一次也不过分的不是？
病人的ESR是正常的，一直afebrile，有4/10 back pain,没有其它地方的pain。她下肢
的力气还是很大的，力量上基本上很对称。没见过PMR case，但感觉应该是有比较
general的疼痛的吧?
上次测gait时忘了做heel to toe。几天特意看了看，她做起来有时不稳，但有时很好
，感觉她的左下肢有些僵直的样子，但muscle tone没问题。
她反复说感觉下肢的tightness，也不是muscle spasm，也不是pain，我真搞不明白这
个tightness是指什么。她说这个tightness在运动之后会加重，所以她都不出去和老公
散步了。谁有经验的给咱解解迷？ | I****a
发帖数: 407 | 10 Neurologist I have learned from in residency likes to order SPEP and viral
hepatitis serology for mysterious polyneuropathy. |
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