The lady with an unexplained subacute progression of bilateral lower extremity weakness

HPI

66 y/o F, presenting with subacute progression of bilateral lower extremity weakness, progressive difficulty gait, some late falls, inability to compensate anymore w/walker. LE swelling of subacute onset.

Admitted to Hospitalist service in the Stepdown ICU.

Additional services already on board: Critical Care, Hospitalist.

Pending consultations: Neurology, Endocrinology, Physical Therapy.

Imaging & Lab Workup

CT-scan of spine – negative for acute process, MRI of head & neck – negative for acute process.

Labs: Only suggestive of reduced albumin. CBC normal.

Physical Examination

Observation: Middle-aged white female, who appeared stated age, supine in bed, reading, wears glasses, pleasant, and in no apparent distress.

Vitals: BP: 114/72 supine; HR – 77; RR – 14; SaO2 – 98% on RA.

Systems Review:

Cardiac: S1, S2, No murmurs, no bruits.

Lungs: CTAB

Motor: UEs 4+/5 bilat. (pt. does not c/o UE weakness), LEs: 2- to 2/5.

Sensory: Crude touch is intact but Fine Touch is impaired. Joint position sensation is suboptimal – impaired in the toes and ankle but preserved proximally

Reflexes: DTRs: 1+ in bilat. knees. 2+ at the elbows. Plantar response is flexor.

Coordination – Intact for finger to nose. Too weak in the lower extremities for heel-shin-test.

Function

Struggles to sit up but able to, both for long-&-short-sitting. Standing is Max to Total assist and support of 2 people essential for safety. Gait is deferred.

Assessment

At this time, please list every possible reason you can think of of WHY do you find the patient in the current situation?

To do this, you will need to have a verifiable PROBLEM LIST.

So, What are the PROBLEMS? >>> WHY are the problems present (i.e. Causation).

You may or may not need to request specific confirmatory tests – but you have to be clear in your mind on what specific test you would want in this situation.

If you can arrive at plausible WHYs, you have solved the problem. The treatment of the underlying CAUSE (the so called “WHY”), is the resolution of the patient’s symptoms.

Everything else as a part of PT is supportive measures – Education, and Prophylactic.

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