Wednesday, 11 June 2008

Another Mind Boggling Case

Dear Bloggers

The following case has, as always, been anonymised to safe guard patient confidentiality and anonymity.  International physicians are also welcome to answer this case history. Please feel free to send in your answers which I will then publish.

This 61 year old male presented with a six-week history of
  • Cough
  • Fever
  • Fatigue and Malaise
  • Numbness and pain in the right hand
  • Pain in the proximal lower limbs, buttock pain and dragging of the left leg
The cough commenced six weeks before admission and the patient considered this to be due to a common cold. The cough was non-productive. There was no associated sinus pain, rhinorrhoea, throat or ear pain. 

The fever had started gradually and had reached up to 38 degrees. There was no associated chills or shaking with the fever. No associated sweats.

The fatigue and malaise had been of relatively rapid onset and the patient had lost his appetite only being able to eat half of his food.

The numbness in the right hand had developed just prior to admission into the hospital. The numbness initially affected the thumb, index and middle finger but then became confluent over the entire palmar aspect of his hand. He did not complain of numbness on the back of his hand. He also described joint pain and was unable to make a fist. 

The pain in the proximal lower limbs was described as a dull ache in the back of his thighs. It was not worsened by movement or coughing. There was no history of any previous spinal pathology and no history of trauma. There was no 'shooting' quality to the pain. The patient had also developed a heaviness of the left leg and he was dragging it when walking. Although he was able to walk  he preferred to be prostrate because of the fatigue and malaise. 

The buttock pain was described as an ache and was localised without radiation. The patient preferred not to lie on his buttocks in bed and instead, laid on his side.

Prior to admission, the patient had sought medical advice from a local clinic on several occasions and several courses of antibiotics had been prescribed which had not resolved the problem.

On further questioning (Body Systems Review):

CVS: No chest pain, no palpitations, no breathlessness.
RESP: No sputum, no haemoptysis, no history of lung disease or TB exposure.
ABDO: No abdominal pain, no nausea or vomiting. No diarrhoea or constipation. No jaundice, normal coloured stool and urine.
MUSC-SKEL: No bone pains, no back pain, no joint swelling or stiffness. 
UROGEN: No urinary symptoms e.g. dysuria, haematuria, frequency, nocturia, urgency, hesitancy, incontinence, feeling of incomplete voidance etc...
CNS: No headaches, no pulsating head pains, no visual disturbance, no jaw claudication or tongue pain on eating. No description of facial numbness or pain. No dizziness or vertigo. No visual disturbance. No auditory disturbance.
ENDO: No thirst, no polyuria, no changes in ability of concentration, no tremor, no sweating, no previous fractures, no recent weight gain  or weight loss. 
SKIN: No complaint of skin rashes or ulceration.

Previous Medical History

Appendicectomy when aged 15 years

Left sided weakness at age of 30 years. No formal diagnosis made. Recovered within 6 months.

Medications- nil

No know drug allergies (NKDA)

Family History

No IHD, no AMI, no HTN, no hyperlipidemia, no diabetes mellitus, no connective tissue diseases.

Social history

The patient was normally well and independent and he worked part-time in a grocery store. He had not been able to work for 1 week prior to admission because of the worsening symptoms.
He was a non-smoker and drank occasional alcohol. He lived with his wife and had two adult sons.

On Examination-- please pay careful attention to the detail here!

General Impression: The patient looked unwell but not seriously ill.

Vital Signs: Temp 38.4 C, BP 140/80, Pulse 110/min (regular), respiratory rate 14/min, SpO2 98% breathing ambient room air. BMI 38.2

General: No clubbing, no splinter hemorrhages, no Janeway lesions or Osler nodes. No conjunctival hemorrhages.  No lymphadenopathy.

CVS: Apex not displaced. No heaves or thrills. Heart sounds 1 + 2. No systolic or diastolic murmurs. No lower limb swelling or evidence of deep vein thrombosis (DVT)

RESP: trachea central and no tracheal tug. Expansion, percussion and auscaultation were normal. Palpation of the chest revealed tenderness along the anterolateral aspect of the ribs bilaterally.

ABDO: Subcutaneous fascia ++. Soft, non-tender, no obvious masses or hepatosplenomegaly. No abdominal bruits and normal bowel sounds. No renal angle tenderness. 

CNS: normal cranial nerve examination.

PNS: tone, reflexes and coordination were all within normal limits. Gross sensation of the upper and lower limbs was normal except the right hand. Sensation of the hand was reduced over the entire palmar aspect including the fingers and the distal dorsal aspects (nail area). The dorsal aspect of the hands had normal sensation. Babinski sign negative bilaterally.

MUSC-SKEL: The right hand was held open in extension. The patient was unable to make a fist because of pain. Examination of each small hand joint revealed pain in the metocarpophalangeal joints of the index and middle finger. There was no increased warmth or swelling. Several of the proximal interphalangeal joints were also painful but not obviously swollen. The wrist joint was not painful or swollen. 

Movements were reduced in extension but particularly flexion of the fingers. The patient was unable to grip paper between his thumb and index finger (pincer grip) or between the index and middle and the middle and ring finger. Testing these movements was not painful.

Power (MMT) of the other remaining limbs was 5/5 (normal)

Examination of the left hand was normal.

Examination of hip movements revealed a normal range of movements which was non-painful. Straight leg raising test was non-painful bilaterally.

Springing of the pelvis with the patient lying on his front elicited pain over the sacro-iliac regions.

Other joints e.g. elbow, shoulders, spine, knees and ankles were within normal examination limits.

ENDO: no tremor, no exopthalmos, no goitre, no pretibial myxoedema, no necrobiosis lipoidica diabeticorum, no acromegallic features, no Cushingoid features (moon face, shoulder hump, striae etc), normal genital size and testicular volume.

SKIN: no focal abnormality identified. No evidence of alopecia.

Questions:

  1. From the history and physical examination, please make a problem list.
  2. What are the possible differential diagnoses in this case?
  3. What tests would you undertake to investigate this patient's problem including both simple and advanced tests?
  4. Give your top three differential diagnoses.
GOOD LUCK !!!

Monday, 9 June 2008

Muscle fasciculation

Dear Bloggers

Muscle fasciculation is something that we have all read about but which we rarely see---unless you actively look for it.

This patient developed a peripheral neuropathy with wasting of the thigh, anterior lower leg and calf muscles causing a foot drop as a result of a vasculitis.

As can be readily seen in the video below, with this patient sitting at rest (hence not using the lower limb muscles), there is spontaneous, involuntary, gross muscle contraction and fasciculation. Please pay close attention to the trough formed between the quadraceps and medial thigh muscles.

    video