OSLER practice case #1 (Neurology)

OSLER Practice Case (Neurology) - #1

The following cases are meant to function as practice cases for students within medicine, neurology, chiropractic, osteopathy or similar healthcare professions which are involved in diagnosing neurological presentations. These are not official OSLER cases, they are made from earned knowledge through a Mchiro programme. Hope you find them helpful. If you have any questions regarding any of the cases please get in touch in the comment field below the article.

OSLER Practice Case – #1

A 45yoa male presents to your clinic complaining of pins and needles in bilateral hands and feet, in a relatively symmetrical distribution. The pins and needles came on 5 days prior to presentation, with unknown quite rapid onset. The tingling has been constant since onset, however it started in bilateral toes and fingers and now seem to involve most of bilateral hands and feet.

The patient saw his GP 2 days ago, and patient states;

_{… “he looked at my feet, and said that the tingling was caused by diabetes” …}

The GP recommended ibuprofen and a follow-up consultation in two weeks if still a problem. Patient was not to happy with this, as patient states;

_{… “I think it might be a trapped nerve in my neck or something!” …}

Nothing seems to aggravate or relieve the pins and needles to any major extent.

When asked about associated symptoms the patient states that he has pain in the cervico-thoracic area around the time of P&N (pins and needles) onset; which has now progressed to involving his right lateral arm to the wrist. Previous medical history revealed that the patient was diagnosed with Type II diabetes two years ago, he also fractured his nose when he was 19yoa playing rugby, besides that he had an inguinal hernia operation (L) ten years ago.

The patient is happy at home, but finds work as an accountant a bit stressful. Patient is currently trying to lose some weight, and is working out 3x week in the local gym. Patient has had no diagnostic imaging of any sorts in regards to the problem.

What are some of the differential diagnoses you might think about at this time in the case?

Examination

General observation: Appears healthy, mildly anxious.

Cranial nerves: II – XII normal

CV exam – not done

Vital signs: BP 160/95 bilaterally PP: 65 HR: 80

Regional examination

Observation:

- No muscle atrophy, swelling, deformity or other trophic changes

Ortho:

- Spurling’s test, distraction test; UL nerve tension tests are all unremarkable.

- Adson’s test causes increased tingling bilaterally

- Tight and tender paraspinal muscles throughout the neck and upper thoracic regions

- SLR: 80 degrees bilaterally – hamstring tightness

Gait/stance:

- A little unsteady on tandem gait

- Heel/toe walking normal

- Mild +ve Romberg sign

Reflexes:

- Upper limbs: All reflexes absent.

- Lower limbs: All reflexes absent including babinski, except for patella reflex which can be seen mildy on reinforced testing

Myotomal strength testing:

- 5 throughout upper limbs, except finger grasp which was rated at 4 bilaterally.

- 5 throughout lower limbs.

Sensation testing:

- Intact to pin-prick & soft touch throughout UL & LL; vibration and joint movement sense intact.

Muscle tone:

- Normal in UL & LL

Coordination:

- Normal in UL & LL

Cervical A-ROM, Lumbar A-ROM full and pain free.

Questions:

2) Is the history taking complete? Are there any other questions you would like to ask the patient?

3) Would you like to conduct any investigations?

4) What is your working diagnosis? And which differential diagnoses might also be possible?

5) What is your management plan for this patient?

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WARNING: Answers below…

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2) No, the history taking is not complete. It is lacking in detailed questioning regarding onset (i.e. any brainstem signs?) and history also completely lacks a systematic review.

3) Investigations which might be beneficial at this time includes nerve conduction studies, electromyograme & CSF sampling,

4) Guillan-Barre (acute inflammatory demyelinating polyneuropathy (AIDP))

5) Refer to GP same day (phone call); with early treatment by intravenous immunoglobulins or plasmapheresis, together with supportive care, the majority of sufferers will recover completely.

Any comments or questions regarding this practice OSLER case? Leave a comment below.