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A 66-year-old male seeks evaluation of difficulty walking. He first noticed this problem 1 week ago. There is no back pain or noticeable weakness. The patient describes his problem as a feeling that he frequently trips. He has no difficult arising from a chair but has tripped while climbing the stairs at home. Past history is notable for adult-onset diabetes mellitus that does not require insulin therapy. The most recent hemoglobin A1C is 6.8%. His only medication is metformin 500 mg twice daily. On physical examination the patient appears comfortable. He has no tenderness or deformity in the back. The left patellar reflex is decreased compared with the right, and there has been a loss of dorsiflexion in the left foot. When walking, the patient has been noted to swing the left leg higher than the right. The term used to describe this gait is steppage. What is the most likely cause of the patient's abnormality?
A. Diabetic neuropathy B. Herniated L5 disc C. Lumbar spinal stenosis D. Middle cerebral artery thrombotic cerebrovascular accident E. Vitamin B12 deficiency
cyra Moderator
Topics: 29 Posts: 844
07/02/06 - 03:12 PM
#2
Thinking its B.
p:s Tough questions nida(my brains fried and I am not even sure of my answers!)...whats the source?
alenka Forum Elite
Topics: 22 Posts: 330
07/02/06 - 04:12 PM
#3
i am lost on this one...
an Forum Guru
Topics: 19 Posts: 437
07/02/06 - 05:10 PM
#4
a.diabetic neuropathy...diabetic lumbosacral plexopathy. ___________________ I don't believe in miracles...I rely on them. And sometimes, I create my own.
guayoman Forum Elite
Topics: 44 Posts: 273
07/02/06 - 06:07 PM
#5
Why an?
what about Ochamīs razor?
___________________ Confidence does not come from simply reading the content, but from doing things with it. Confidence is born in the flash of insight, in the ability to face something new and figure it out. Kaplan usmle edge newsletter
msyamp Forum Fanatic
Topics: 60 Posts: 1,462
07/02/06 - 06:26 PM
#6
it too go with diabetic. lumbosacral plexopathy. word seems interesting but yes it is an LMN unilateral leision.not disc prolapse as no history suggestive. ___________________ If you think you can You can! If you think you cant you are right again!!
an Forum Guru
Topics: 19 Posts: 437
07/02/06 - 07:00 PM
#7
pure motor symptoms without sensory involvement in lower limb in diabetic pt, esp type 2 is characteristic for plexopathy..also goes by other names like diab amyotrophy...
cant fit any of the other ds in clues with symptomatology, guayoman..choice A is the ocham's razor for me
___________________ I don't believe in miracles...I rely on them. And sometimes, I create my own.
cyra Moderator
Topics: 29 Posts: 844
07/02/06 - 07:41 PM
#8
whats bothering me about this is that there is unilateral involvement of the motor nerve....the loss of dorsiflexion points to L5 being affected.Is it possible to have such a presentation with diabetes?I'd have expected it to be sensory in the first place and bilateral.My occam's razor would have to be B.
msyamp Forum Fanatic
Topics: 60 Posts: 1,462
07/02/06 - 08:02 PM
#9
basically you are luring me with the chocolate cookie and yes diabetes can present with unilateral nerve involvement. like in mononeuritis mutiplex ___________________ If you think you can You can! If you think you cant you are right again!!
cyra Moderator
Topics: 29 Posts: 844
07/02/06 - 08:17 PM
#10
Right...but mononeuritis doesn't fit here.Good thing is I looked up mononeuritis multiplex and read up on it.From emedicine: http://www.emedicine.com/PMR/topic80.htm
"Mononeuritis multiplex is a painful asymmetric asynchronous sensory and motor peripheral neuropathy involving isolated damage to at least 2 separate nerve areas. Multiple nerves in random areas of the body can be affected. As the condition worsens, it becomes less multifocal and more symmetric. Mononeuropathy multiplex syndromes can be distributed bilaterally, distally, and proximally throughout the body."
At the risk of souding bratty...I still think its B...(guess we'll find out tom when nida posts the right answer)
p:s the cookie is actually a samoa...its coconut and chocolate!
frontal Forum Guru
Topics: 53 Posts: 421
07/02/06 - 10:02 PM
#11
Sciatic nerve involvement, esp. of its peroneal branch, manifesting as foot-drop. Without history of sciatica or even back pain and with a history of diabetes, I'd choose diabetes as the likely etiology.
MAZI Forum Elite
Topics: 8 Posts: 245
07/03/06 - 08:09 AM
#12
hi cyra
the defect in this patient is : L4 due to absent knee jerk and L5 due to absent foot dorsiflexion, if you have a herniated disc in L5 you have a nerve defect in S1 and then impaired plantar flexion of foot ( one level below herniated disk ) and absent ankle jerk, when you have impaired knee jerk you must have a herniated disk in the level of L3_L4.
this patient has a different defect in different site ,without any lumbar sign and symptom (eg, pain,.. ), the defect is in any site distal to the nerve root ,i think that it is not herniated but i dont know what kind of diabetic neuropathy, it is not a diabetic amyotrophy because the is no pain and proximal atrophy
nida Forum Elite
Topics: 23 Posts: 87
07/03/06 - 01:41 PM
#13
The answer is B. The patient has a steppage gait, which is caused by weakness of ankle dorsiflexion. Because of the footdrop, the leg must be lifted higher than usual to avoid dragging of the toe when he steps forward. As the condition described in this case is unilateral, the finding of left ankle weakness is most consistent with an L5 radiculopathy. Diabetic neuropathy and vitamin B12 would be expected to cause bilateral sensory neuropathies. The weakness after a cerebrovascular accident is not localized to a single nerve root. The gait associated with this is described as hemiparetic and is notable for elevation and circumduction at the hip with contralateral tilt of the trunk. Finally, lumbar spinal stenosis should cause a paraparetic gait with scissoring related to bilateral lower limb spasticity.
(From Harrison Self-Assessment test)
an Forum Guru
Topics: 19 Posts: 437
07/03/06 - 02:59 PM
#14
alright...good qu nida, and good explanation too...well done cyra.. ___________________ I don't believe in miracles...I rely on them. And sometimes, I create my own.
frontal Forum Guru
Topics: 53 Posts: 421
07/03/06 - 08:01 PM
#15
Thanks nida. So, unilateral is the catch. Though motor involvement in diabetes may well be asymmetric, if diabetic amyotrophy is the name for this, it cannot be this, for the reason given by MAZI. The main reason why I did not choose L-5 herniation was the clearly mentioned absence of pain, but apparently I didn't know enough. Harrison's gotta be right. How did you guys figure Disc herniation? By exclusion, I guess.
docofthebigapple Forum Senior
Topics: 25 Posts: 185
07/10/06 - 08:00 AM
#16
Give me the clinical picture for this patient if he had S1 disc herniation in terms of gait changes, loss of which reflexes, loss of sensations over what part of the leg etc etc.
Lets extend our coverage right here because L5 and S1 are the most commen sites of disc herniation.
msyamp Forum Fanatic
Topics: 60 Posts: 1,462
07/10/06 - 09:31 AM
#17
Woow thank you very much. NIDA ___________________ If you think you can You can! If you think you cant you are right again!!
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