numbness and tingling

HPI

The patient is a 22 y.o. female with a past medical history of anemia and vitamin D deficiency who presents with numbness/ tingling. The patient states about a month ago she had a routine physical with her PCP where they found her to be anemic and vitamin D deficient. At that time she was started on iron and Vitamin D. About a week ago the patient began having complaints of numbness and tingling. She states that one week ago the numbness/ tingling was in her toes, and within a few days it moved up to her feet/ ankles. She then awoke with numbness of her fingers which has now traveled up her bilateral hands. Today the patient awoke with facial symptoms. She is not able to do a full smile on the R side and has noticed numbness/ red splotches on the tip of her tongue. The patient also has some vague complaints of diarrhea/ loose stools in the early morning for the past 4-5 days. The patient also has been having back pain, which is across her back, tight feeling into her shoulders, with a piercing sensation in her L shoulder. The patient also complains of headache for the past couple of days along with fatigue and increased sleepiness. The patient was previously healthy but did have a viral URI about 3 days ago with cough, congestion and rhinorrhea. She does work in a day care and states this is not uncommon for her as she is around sick children all of the time. The patient denies any chest pain or shortness of breath but states she feels like she has to think to swallow at times. The patient denies any rash.

PHYSICAL EXAM

VITAL SIGNS: Blood pressure 117/76, pulse 85, temperature 98.1 degrees F (36.7 degrees C), temperature source Oral, resp. rate 16, height 5′ 4″ (1.626 m), last menstrual period 07/20/2012, SpO2 98.00%.

Constitutional: Well developed, well nourished, no acute distress, non-toxic appearance

Eyes: R pupil not reactive to light. L pupil direct and consensual reaction to light. EOMI. No drooping. R eye easily opened when patient told to squeeze eyes closed compared to left.

HENT: Atraumatic, external ears normal, nose normal, oropharynx moist. Tip of tongue with red bumps. Neck- normal range of motion, tenderness to C and T spine, supple.

Respiratory: No respiratory distress, normal breath sounds, no rales, no wheezing

Cardiovascular: Normal rate, normal rhythm, no murmurs, no gallops, no rubs.

GI: Soft, nondistended, normal bowel sounds, nontender, no organomegaly, no mass, no rebound, no guarding

Musculoskeletal: No edema, no tenderness, no deformities. Back- tender on C and T spine and across bilateral scapulae on palpation.

Integument: Well hydrated, no rash

Neurologic: CN exam significant for decreased strength of keeping eye closed on R. Decreased smile on R. Patient unable to feel my touch on either feet. Able to dorsi and plantar flex bilaterally but weakened. no reflexes throughout. Patient careful when walking as cannot feel her feet but no foot drop. Patient has decreased fine touch but normal pinprick to bilateral upper extremities. Normal strength upper extremities. Patient unable to stand on toes.

MDM: 22 y/o F with diarrhea, numbness, tingling, weakness, fatigue and headache. She also has a bell’s palsy. Unsure is calcium is an issue. Will need to call neurology for evaluation. Likely a Guillan barre picture based on history of antecedant illness, no recent travel, and will need LP to confirm. Lyme Disease also in the differential, but less likely as no known previous known tick bite and lives in central ohio. We also considered electrolyte issues, hypo/hypercalcemia as patient’s recent start on vitamin D, but again less likely as vitamin D is usually a benign medication. Thyroid issues were in the differential as mom has a history of grave’s but this was recently checked at OSH and was normal. MS is still a possibility. If normal LP, MRI can be considered as inpatient.

Labs= unremarkable

LP= Protein CSF= 93,000

Neuro consult.

Teaching points=

1) Kade-ism= “Normal people don’t come into the ER unless there is something wrong”.

2) Outside hospital did thorough workup, including hormones, etc… However until progression of disease in a couple of days were we able to get a clearer picture of what is going on.

3) PRESENCE OF REFLEXES pretty much EXCLUDES Guillan Barre syndrome. 

4)Have the patient kneel on a chair if you are able to and attempt to elicit ankle reflexes by tapping back of ankle– this should be strong especially in young healthy people.

5) Miller Fisher Syndrome=  The typical presentation of MFS is that of ophthalmoplegia with ataxia and areflexia.  About one-quarter of patients who present with MFS will develop some extremity weakness, clearly linking this disorder to GBS. A limited form of MFS presents as cerebellar ataxia and hyporeflexia without ophthalmoplegia.

6)Attending neurologist told resident who informed me that it is classic presentation to have GBS.  It is classic to have Bell’s palsy– he expects her to have bilateral facial weakness by tomorrow.

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