cbenitesch
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56 yo female comes to your office complaining of dizzines, kind of tingling on her arms and hands, she denies fever, nausea, vomit. PMI Recurrent urinary tract infection on this year, she just finished treatment for an E. coli UTI some days ago, her sister died recently because of breast cancer, she has a grandson with a neurological problem. PE: 126/82, 80bpm, 12 rpm she looks worry, slow thinking, Romberg (-), coordination ok, when you ask her to walk over a staight line she becomes unstable and almost fall down. Lab values are unremarkable. Whatīs the next step?
a) order a CT scan of bain.
b) call the neurologist to evaluate her.
c) call the cardiologist to evaluate her.
d) ask for more info.
e) discharge her without medication and re-evaluate next week.
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| tolito
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sonds like vertebral artery stenosis.
i will choose D. i want to find out more about the dizziness. is it pre-syncope or vertigo? is it central or peripheral vertigo?
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| GDS2008
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I am kinda confused as well, so I will D. ask for more info
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| shumaila
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a???
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| study_ing
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hmm confusing..b, c and e are definitely out. u dont hand over ur patients neither do u ldispose of them if theyre likely to fall and hurt themselves.
it cud be a neurological cause.
tingling + family history
slow thinking + falls ( early presentation of one of a dementias which i cant recall)
d sounds safe...but i dont recall what's happening to the pt..as in what r we looking for here.
cud be CVS cause too but CNS is a possibility
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| frank100
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(d) more history: I can rule out some type of MEN just by askng, recurrent UTI points toward some mild immunodeficiency, maybe TSH levels can rule out a thyroid disease or at leat give me some light, CT scan can rule out some types of dementia, etc... but otherwise this is one of those weird syndromes mockin around
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| fox
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imbalance while walking in a straight line is suggestive of cerebellar Ds.....I would go for A. But that does not explain the tingling sensation that she has. Whats the answer?
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| GDS2008
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This can be vitamin B12 deficiency, vascualr problems, late MS or other variety of problems. Therefore you need to ask her more question (that is option D). Just to clear a few things for fox -- if u r suspecting a cerebellar disorder, CT scan is not a good dioagnostic modality for imaging posterior fossa pathology (MRI is the test of choice). Based on this I do not think that can be the answer.
I am pretty confused about the diagnosis myself. However, one rule which I am following here is: If an option asks you to probe more into the history or physical examination, that usually is the right answer. Consider it this was -- what would you do i a patient presents to you with just these symptoms in the clinic. Would you not like to ask her more questions first before ordering a test that costs about >1000 bucks... so this is what we will do on the actual exam
Edited by GDS2008 on 08/30/06 - 12:48 PM
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| fox
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U have raised a valid point GDS2008...i too would be inclined to think in ur direction.
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| Isther
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I agree... Ask more info... 
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| study_ing
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thanx cbenistech...one of those where the answer is agreed upon, yet the discussion is valuable 
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| cbenitesch
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Well friends... answer is ask for more information!.... This is a real case, the question has several distractors, but the main stuff is the recurrent UTI of this lady, and she acknowledge the end of treatment for UTI. We need more information why? because amantadine or nitrofurantoine has serious adverse effect, the most frequent I saw on daily practice is dizziness, thatīs way Romberg is (-) but she is unstable to walk over a straight line. I just found some questions same like this where we have to consider side effects when clinical exam is not consistent.
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| cbenitesch
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Study_ing your answer on #5 was a really good differential, I included that on mine too! GDS2008 nice opinion on B12 defficiency!...
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| study_ing
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thanx cbenitesch for bringing this up..im glad the forum's alive with discussion these days..it always helps to know y the other options are wrong for sure
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