We all love puzzles/case studies.

[Rolf]

Here is a case study I would like your take on (the medical student take..) After you read this, respond with your thoughts, and your year, if you would.
There are NO wrong answers here. No judgements, no pressure, just learning.
One other thing - try to respond before looking at the other responses if you can withstand the temptation.

BTW _ PM me if you would prefer


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75 year old woman. No known drug allergies.

Past Medical history: Chronic Respiratory Failure, chronic obstructive pulmonary disease, Abnormal Posture, Atrial Fibrillation, Recurrent Urinary tract infections, Hyperlipidemia, heart failure, Generalized Weakness, Depression, Bipolar, Osteoporosis, Osteoarthritis, Insomnia, Allergies, gastro esophageal reflux, Essential Tremor, RLS, Neuropathy, hypertension, Constipation.

Medications: Nitroglycerin PRN, Melatonin, Cranberry Tablet, Tylenol, Cyanocobalamin, Iron, Vitamin C, Sinemet, Pepcid, Miralax, Senna S, BuSpar, Trintellix, Bacolofen, Tramadol, Biofreeze, ASA, Vitamin D, Folic Acid, Artificial Tears, Atorvastatin, Calcium, Apixaban, Primidone, Diltiazem, Bethanechol, Amiodarone, Lisinopril, Gabapentin, Methenamine Hippurate, Pulmicort, Lamictal, DuoNeb, Tumeric.

About 6-7 weeks ago started complaining of left shoulder pain, no injury. XRAY negative. The pain then moved to the right shoulder and back, both XRAY negative with exception of degenerative changes to back. She then complained of pain in the left breast (denied chest pain). Breast Exam Nl. Labs drawn, complete blood count normal . complete metabolic panel normal . urinalysis +. Treated for urinary tract infection.
She is normally incontinent.

Pains continued and moved to different sites every week - last week she complained of chest pain and 'severe' abdominal pain. A full work-up was done as an outpatient because her complaint is different every week. EKG shows sinus rhythm.

Today, she says she "has no feeling" in either leg and that she can't move her legs for the last day or two. Sheis having to ask others to help her do it. She refuses to get out of bed. She refuses to go to hospital. She routinely will not go to follow up appointments. She does have sensation decreased to bilateral legs upon exam and could wiggle her toes a little. No pain in legs at all.

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Yes – this situation is messy – because it is real life – full of distractors.

What are your thoughts? If you can think of only one Dx (or none) that is fine, if you have more ideas – A diff Dx, add the others in.
What would be your next step?

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[EmilKraepelin55]

Just finished M2 here, but since she has a Dx of neuropathy, presumably the reason she takes B12 supplements, then I suppose it could be noncompliance.

Also perhaps:

Polymyalgia rheumatica

Polymyositis

Functional neurologic syndrome

Fibromyalgia


Labs:
B12/Folate levels
Serum CK
ESR/CRP

*edit: Just saw normal CBC, so perhaps not a B12 issue lol.

 

[Rolf]

Thanks - answer will be on its way in a few days~!

 

[FrkyBgStok]

I am a PGY-4 in a peds fellowship. My answer: she is a liar.

 

[calivianya]

Just finished second year. She might be old and have a ton of chronic health conditions, but does she have a nice back porch in the northeastern US to sit on? I’m wondering if it’s chronic Lyme.

Also she just seems lonely. Asking who she lives with would help - if she’s in a nursing home, and her kids never visit, maybe she is just trying to have some human interaction other than burned out nursing home CNAs and RNs.

 

[EmilKraepelin55]

Just finished second year. She might be old and have a ton of chronic health conditions, but does she have a nice back porch in the northeastern US to sit on? I’m wondering if it’s chronic Lyme.

Also she just seems lonely. Asking who she lives with would help - if she’s in a nursing home, and her kids never visit, maybe she is just trying to have some human interaction other than burned out nursing home CNAs and RNs.

Do you mean post-treatment Lyme disease syndrome? Because chronic Lyme disease isn’t a real clinically defined entity.

 

[calivianya]

Do you mean post-treatment Lyme disease syndrome? Because chronic Lyme disease isn’t a real clinically defined entity.

Possibly! I saw a patient while I was shadowing that has similar symptoms, with migratory joint pain, after he’d had Lyme for a couple of years without getting an accurate diagnosis. No one had believed him (this was an area where Lyme wasn’t common), so he had finally ordered an antibody test (I think) through a site where you pay to get an order for tests without seeing a physician, and was able to receive treatment.

It’s possible the patient could have current Lyme or post-treatment Lyme.

 

[EmilKraepelin55]

Possibly! I saw a patient while I was shadowing that has similar symptoms, with migratory joint pain, after he’d had Lyme for a couple of years without getting an accurate diagnosis. No one had believed him (this was an area where Lyme wasn’t common), so he had finally ordered an antibody test (I think) through a site where you pay to get an order for tests without seeing a physician, and was able to receive treatment.

It’s possible the patient could have current Lyme or post-treatment Lyme.

Very interesting. Did the patient complain of syncope, or have undiagnosed heart blockhouse uncovered? Any neurological sequelae? These things tend to occur months after the initial infection. With Post-Tx Lyme you will have Lyme-like sx due to poorly understood immunological phenomena. Although if the patient was never treated I suppose they could have cleared the infection on their own and still developed the syndrome.

 

[calivianya]

Very interesting. Did the patient complain of syncope, or have undiagnosed heart blockhouse uncovered? Any neurological sequelae? These things tend to occur months after the initial infection. With Post-Tx Lyme you will have Lyme-like sx due to poorly understood immunological phenomena. Although if the patient was never treated I suppose they could have cleared the infection on their own and still developed the syndrome.

He definitely had syncope, fatigue, and long-standing peripheral neuropathy. He had been an athlete before and reported surfing most days of the week, but reported being so fatigued that he couldn’t walk too far even after the Lyme, so I bet he did have some heart issues as well. He was in his late 20s and looked pretty cachetic to me.

 

[kraskadva]

Rising M4 here.

I think Lyme is reasonable on the ddx though I don't see this lady spending too much time outside. Gillian-Barre to go with that for good measure, though unlikely.
I'd also want a r/o of aortic aneurysm (migratory pain + new onset neurological complaint w/o specific nerve distribution)
If she turned up negative for those, and after a thorough med review because that's some heavy poly-pharmacy and odds are there's an interaction in there somewhere, then a psych eval.