The Case
Chief Complaint: Trouble walking
Janeen Wright is a 73-year-old woman who is coming to her primary care office for numbness and weakness of her left leg. It’s hard for her to tell exactly when the problem started, but she thinks she first noticed it a few months ago and says she has now fallen a couple of times while walking because her left leg “just kind of gave out on me” while she was walking. Both legs “feel funny, kind of stiff and clumsy,” but the left leg is definitely worse than the right. She usually walks a few miles a day for exercise but has been afraid to for the last several weeks.
She has a history of back pain due to degenerative disk disease for which she takes Tylenol as needed, and says her back has been acting up more lately, requiring her to use a heating pad to sleep at night.
When asked about bladder or bowel changes, she says she has been more constipated than usual and has had to take some Milk of Magnesia. Her bowel movements have been soft, the usual size, and there is no blood in them/color change when they do occur. She has some baseline urinary dribbling “when she waits too long to pee” and does not think this is different.
PMHx:
- Degenerative disk disease seen on MRI in 2008, treated with physical therapy and acetaminophen
- Stage 3 breast cancer treated with mastectomy and chemotherapy in 2012, in remission, now on Arimidex, followed by oncology annually
- Chronic kidney disease, stage 3, followed by nephrology
- renal osteodystrophy, also followed by nephrology, taking cholecalciferol and calcium acetate
- Hypertension, also followed by nephrology, currently taking furosemide, amlodipine, and Lisinopril
- Total knee replacement on left for osteoarthritis in 2004
Exam:
| Test | Value |
|---|---|
| T | 98.4 |
| HR | 72 |
| BP | 135/75 |
| RR | 12 |
| SpO2 | 99% |
GEN: awake, alert, pleasant
HEENT: mucus membranes moist, good dentition, pharynx and TM’s normal, neck has full range of motion without pain
CV: rrr, no murmurs, pulses 2+. No S3 or S4.
Lungs: clear bilaterally, no increased work of breathing
Abd: soft, protuberant, no masses or organomegaly palpated
Rectal: normal tone, anal wink intact, pt. unable to voluntarily clench or relax anal sphincter
Neurologic:
- Higher function; short-term memory intact, oriented x 3, concentration intact, speech production and receptive ability appear normal.
- Motor: no dysdiachokinesia of upper extremities, DTR’s 2+ in upper extremities and right lower extremity, 3+ in left patellar and 4+ in left Achilles, 5/5 strength in all 4 except 4/5 strength in iliopsoas mm. Left foot toes flare out when sole of foot is stroked from heel to toe. Walks with stiff legs and appears unsteady on gait testing.
- Sensory: Pain sensitivity decreased on right body below umbilicus. Position sense and temperature perception decreased on left leg and foot.
Diagnostic testing:
Stop here and make a list with your group of the diagnostic tests you think are necessary in this patient at this time. Your tutor has test results and can give/show them to your group when your group feels your list is complete.
