symptoms chief complaint = “i am getting weak” painful sensations with increasing muscle...
TRANSCRIPT
![Page 1: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/1.jpg)
CPC CASE NUMBER 1
![Page 2: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/2.jpg)
Symptoms
Chief Complaint = “I am getting weak” Painful sensations with increasing
muscle weakness in both LE (started in ankles)
Prickly numbness and tightness in lower abdomen
![Page 3: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/3.jpg)
H & P Findings Coronary Artery Disease Campylobacter jejuni diarrhea a few weeks
ago, successfully treated with antibiotics Smokes 1 ppd Vitals Normal except BP Δ from 130/80 to
90/60 when going from supine to standing. Absent patella and achilles reflex Decreased pain and touch in feet Decreased proprioception in LE
![Page 4: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/4.jpg)
CLASS DIFFERENTIAL ?
![Page 5: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/5.jpg)
Our Differentials
Diabetes Herniated Disc Neoplasia Lead Poisoning Demyelinating Disease
![Page 6: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/6.jpg)
DIABETES
![Page 7: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/7.jpg)
Diabetic Peripheral Neuropathy
Diabetic nerve pain result of damage to nerves because of high blood sugar levels over time.
Can affect any nerves and thus a list of possible symptoms, but usually develop over a number of years.
Causes;Not totally clearBelieved to be a number of contributors
○ Metabolic, neurovascular, autoimmune factors○ Mechanical injury to nerves, inherited traits, or
lifestyle factors
![Page 8: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/8.jpg)
Diabetic Peripheral Neuropathy Symptoms that Correspond
painful sensations and increasing muscle weakness of both lower extremities.
has difficulty rising from a chair, climbing stairs, and complains of an unsteady gait.
a prickly numbness in both legs and a band-like tightness across his lower abdomen
indigestion, nausea, or vomitingdiarrhea or constipationloss of reflexes
![Page 9: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/9.jpg)
Diabetes
Hemoglobin A1C - $37On high side of normal range 6.1 (3.8-6.4)
![Page 10: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/10.jpg)
HERNIATED DISC
![Page 11: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/11.jpg)
Herniated Disc
Bulging of nucleus pulposus, with or without nerve root compression
Most common in lumbar region Symptoms:
Back painLeg pain
Occurs mostly in 30’s and 40’s
![Page 12: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/12.jpg)
Herniated Disc
Patient’s symptoms consistent with disc herniation:Painful sensations in LETingling sensations in LEMuscular weakness in LE
![Page 13: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/13.jpg)
Herniated Disc
Patient’s symptoms inconsistent with disc herniation:Bilateral LE pain uncommon25 y/oAtaxia
![Page 14: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/14.jpg)
Herniated Disc
X-ray of LS spine - $190Normal
MRI spine - $1400normal
![Page 15: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/15.jpg)
NEOPLASM
![Page 16: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/16.jpg)
Cauda Equina Syndrome
Compression of large nerve trunksTumor, infection, narrowing of spinal canal
![Page 17: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/17.jpg)
Cauda Equina Syndrome
His symptoms that correspondProgressive loss of sensationMuscle weakness
![Page 18: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/18.jpg)
Cauda Equina Syndrome
His symptoms that don’t correspondBowl or bladder dysfunctionNo muscle atrophy
![Page 19: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/19.jpg)
Neoplasia – Cauda Equina Syndrome
MRI spine - $1400normal
![Page 20: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/20.jpg)
LEAD POISONING
![Page 21: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/21.jpg)
Lead Poisoning
Occupational Hazard: potential lead exposure
His symptoms that correspondPain, numbness, and tingling in the
extremitiesMuscle weaknessAbdominal Tightness
![Page 22: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/22.jpg)
Lead Poisoning
Headache Memory Loss Mood Disorder
![Page 23: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/23.jpg)
Lead Poisoning
Blood lead testNormal range for unexposed individual
![Page 24: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/24.jpg)
DEMYELINATING DISEASE
![Page 25: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/25.jpg)
Demyelinating Disease
Blood Glucose87 (70-110)
LPNormal CSF glucose 100 ( > 2/3 BG) and
high CSF protein 85 (25-45) EMG – nerve conduction
40% slowed nerve conduction in legs. Indicates proximal demyelination
![Page 26: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/26.jpg)
GUILLAIN BARRE = DX
![Page 27: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/27.jpg)
Guillain-Barre Syndrome
General information:Immune system attacks peripheral nerves
○ Antibodies generated for C. jejuni attack gangliosides in PNS
Ascending starting w/ weakness and tingling in legs
Potential to ascend to C3-5 and affect diaphragm/respiratory innervations
Rare 1:100,000 affectedRecovery ranges from weeks to a few years
![Page 28: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/28.jpg)
Guillain-Barre Syndrome National Institute of Neurological Disorders and Stroke
(NINDS) Diagnostic Criteria1:Required Features:
○ Progressive weakness of more than one limb, ranging from minimal weakness of the legs to total paralysis of all four limbs, the trunk, bulbar and facial muscles, and external opthalmoplegia
○ Areflexia. While universal areflexia is typical, distal areflexia with hyporeflexia at the knees and biceps will suffice if other features are consistent
Supportive Features:○ Progression of symptoms over days to 4 weeks○ Relative symmetry○ Mild sensory symptoms or signs○ Elevated CSF protein with a cell count <10mm3○ Electrodiagnostic abnormalities consistent with GBS
![Page 29: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/29.jpg)
Guillain-Barre Syndrome Patient: Dx
High CSF protein w/o increased cell countEMG showing conduction slowing and loss of F
wavesCommonly follows infection
○ camplyobacter jejuni, CMV, Epstein-Barr, herpes, and viral hepatitisU.K. study showed that 26% of GBS affected Pts had
evidence of a recent C. jejuni infection2
Swedish study estimated that the risk for developing GBS within two months of C. jejuni infection was 100x higher than risk in general population3
Orthostatic hypotension (130/80 to 90/60 )
![Page 30: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/30.jpg)
Guillain-Barre Syndrome
Acute inflammatory demyelinating polyneuropathyMost common form of GBS in the United States
and Europe, representing 85-90% of cases.Earliest abnormalities see on clinical
neurophysiology studies are prolonged or absent F waves, reflecting demyelination at the level of the nerve roots.4
![Page 31: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/31.jpg)
Treatment No known cure High dose of intravenous immunoglobin
(IVIG) therapy or plasma exchange therapyEqually beneficial with no apparent benefit of
combining the two therapies Long-term management of neuropathic pain
tricyclic antidepressants, gabapentin, carbamazepine
Monitor for progression of disease
![Page 32: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/32.jpg)
What bacterial infection commonly precedes Guillain Barre?
A. Strep agalactiae
B. C. jejuni
C. Epstein Barr
D. Cryptococcus
E. Serratia Marcescens
![Page 33: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/33.jpg)
Which of these can cause peripheral neuropathy?
A. Diabetes
B. Lead Poisoning
C. Cauda Equina
D. Guillain Barre
E. All of the above
![Page 34: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/34.jpg)
What is the treatment method for Guillain Barre?
A. Surgery
B. Blood Transfusion
C. Plasma Exchange
D. Amputation
E. All the above
![Page 35: Symptoms Chief Complaint = “I am getting weak” Painful sensations with increasing muscle weakness in both LE (started in ankles) Prickly numbness](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649cd65503460f9499d835/html5/thumbnails/35.jpg)
Sources 1. Criteria for diagnosis of Guillain-Barre Syndrome. Ann Neurol
1978; 3:565. 2. Rees, JH, Soudain, SE, Gregson, NA, Hughes, RAC.
Campylobacter jejuni infection and Guillain-Barre Syndrome. NEngl J Med1995; 333:1374.
3. McCarthy, N, Giesecke, J. Incidence of Guillain-Barre syndrome following infection with Campylobacter jejuni. Am J Epidemiol 2001; 153:610.
4. Gordon, PH, Wilbourn, AJ. Early electrodiagnostic findings in Guillain-Barre Syndrome. Arch Neurol 2001; 58:913.