Here is August's case. It is a great one for sure! Please have a go and see if you can get the diagnosis!
A 65 year old lady was admitted to the hospital with loss of consciousness.
She had been found by her husband having collapsed in the toilet at 3am. The loss of consciousness had been unwitnessed but the patient was found to have urinary incontinence. Her husband called for an ambulance and she was transferred to the ER department. There was no obvious head trauma and no tongue biting.
The patient later became rousable in hospital and admitted to feeling dizzy when standing over the last few days. The patient also had some loose stools over the preceding days prior to admission but she described the colour as normal. There had been no associated abdominal pains. She denied straining whilst defecating.
She also admitted to recent ‘pins and needles’ in her left arm and some double vision over the preceding days prior to admission. She had no perioral paraesthesia.The symptoms had come on gradually and nothing had made them better or worse.
She denied the following symptoms
- CVS: No chest pains, no palpitations, no leg swelling
- RESP: No cough, bo sputum, no breathlessness
- ABDO: No nausea, novomiting, no haematemesis, no malaena, no swelling, no jaundice.
- Musc: No muscle pains, no weakness, no joint problems.
- URO: No frequency, no nocturia, no haematuria.
- CNS/PNS : No headaches, no visual loss, no speech disturbance, no hearing loss. No weakness of arms or legs. No unsteadiness.
- Endo: No excessive thirst, no tremor, no sweats, no weight loss
- Skin: no skin problems
Previous Medical History
• Right adrenal tumour – diagnosed 5 years ago. The patient had undergone unilateral adrenalectomy but she was uncertain of the final diagnosis.
• Paroxysmal Atrial Fibrillation (PAF)
• Disopyramide 40mg 4x/day
• Aspirin 81mg/day 1x/day
• Allopurinol 100mg/day 1x/day
• Voltarol 50mg 3x/day
• Ranitidine 150mg 2x/day
• Lactulose 10ml 2x/day
• Senna two tablets 1x/day
No Known Drug Allergies
Family & Social histories: these were uncertain on the admission day
General: Patient was alert. GCS 15/15 and was oriented in time, place and person. Afebrile.
No JCCO; conjunctival pallor (+), rubbery, mobile, smooth lymph nodes (+) in the left and right axillae. Maximum diameter of the LNs approx. 15mm.
HEENT: No evidence of fracture or soft tissue injury. Tongue was atraumatic. Mouth did not demonstrate any blood. Ears - no blood or fluid. Nose - no blood or fluid.
CVS: Pulse 110 / min, regular. BP 86/70mmHg. JVP not elevated. No heaves or thrills. Apex in normal position. Heart sounds 1 + 2 normal. No S3 or S4. No murmurs. No leg edema or signs of calf swelling / pain / redness.
RESP: RR 16/min, SpO2 95% on room air. Trachea was central. Percussion note was resonant. Auscaltation revealed normal vesicular breath sounds.
ABDO: Soft, non-tender, no masses, no hepatosplenomegaly, no inguinal lymphadenopathy. No bladder distension, and no renal angle tenderness. Rectal exam – black stool.
Musculoskeletal: No focal abnormalities
II: grossly normal visual fields. Pupils equal and reactive to light and accommodation + consensual response. Proptosis of the left eye.
III/IV/VI: impaired abduction of the left eye with associated double vision when looking to the left lateral side. Other eye movements were all normal.
V: Normal motor and sensory components
VII / VIII /IX / X / XI / XII: all grossly normal.
Tone – normal throughout the upper and lower limbs
Power – Upper and lower limb power 5/5 throughout
RUL LUL RLL LLL
Supin +/- ++ +/- +/-
Biceps +/- ++ +/- +/-
Tricep +/- ++ +/- +/-
Knee +/- +/- +/- +/-
Ankle +/- +/- +/- +/-
Sensory: Gross sensation , nociception and joint position senses appeared intact.
Coordination: No cerebellar signs
Fundoscopy was not performed.
Endocrine: no tremor, no thyroid enlargement, no evidence of bitemporal hemianopia.
Skin: no focal abnormality
Question 1: From the history and examination, please make an appropriate problem list.
Question 2: Please provide a differential diagnosis (es).
Question 3: What would you immediately do for this patient?
Question 4: What tests would you perform and why?
Question 5: What other bedside physical examination test(s) could provide additional information to aid your diagnosis?