darkhorse
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You are a physician practicing in a small community in the Rocky Mountains near Aspen,
Colorado. A 33-year-old female comes to your office for evaluation of a bilateral tingling
sensation in the fingertips. She describes the sensation as affecting all the fingers on both
hands. She has no medical problems and takes no medications. She is a vegetarian and is
visiting the area from San Diego, California. She denies any other symptoms, including
headache, nausea, vomiting, shortness of breath, and urinary frequency. On physical
examination the patient has a normal sensory examination, including reaction to light touch and
pinprick and vibratory sensation. She is able to stand normally with the arms extended and the
eyes closed. A cerebellar examination reveals normal finger-to-nose testing and no
dysdiadochokinesis. Her gait is normal, including tandem gait, toe walking, and heel walking.
What would you recommend as the next step?
A. Blood tests for serum vitamin B12
B. Fasting blood glucose level
C. Reassurance
D. Serologic testing for syphilis
E. Treatment with acetazolamide for altitude sickness
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| cool doctor
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A
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| sprint123
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B12, Syphilis ---> I would expect posterior column lesions...In this woman, with only numbness and NO other signs irelating to posterior column lesion..I thin these two are highly unlikely.
Altitude sickness doesn't fit.
Diabetes ---> Glove and stocking neuropathy --->Maybe...But with only finger tips--Not atrtractive,
The missed one is REASSURANCE
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| sukhs
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reassurance
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| cool doctor
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She is a vegetarian
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| mjl1717
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cool doctor wrote:
She is a vegetarian
yes B12
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| me007
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why would ppl always suspect vegeterians in whatever deficiency?
sources of B12 for vegetarins:
breakfast cereals in this country are always fortified with B12; milk products (she is not vegan) and eggs
actually answers A and D will have same "sensory ataxia" - loss of position sensation from the feet.
Edited by me007 on 11/11/07 - 11:31 AM
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| titly
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the patient mite b showing initial signs of B12 deficiency. i think we should order serum B12 levels and if dats normal she can jus b reassured.
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| dudefop
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You can't be too careful in examining your patient.
A. Vit B12
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| darkhorse
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The answer is C.
The patient's nonspecific dysesthesia is related to hyperventilation in response to the patient's
change in altitude from sea level to a mountainous area. The normal respiratory response to
decreased atmospheric oxygen tension is to increase the respiratory rate. This hyperventilation
causes a mild respiratory alkalosis and is experienced as acral and periorbital dysesthesias.
Acetazolamide is often given to patients who have a past history of altitude sickness manifested
as headache, nausea with vomiting, and in severe cases pulmonary edema. This patient is
experiencing none of those symptoms, and in fact, dysesthesias are a common side effect
related to treatment with acetazolamide. No further blood testing is necessary as the symptoms
are not associated with any neurologic abnormalities. Diabetes mellitus, vitamin B12 deficiency,
and tertiary syphilis are all associated with a sensory neuropathy, which this patient does not
demonstrate.
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| cool doctor
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if you see dr.fisher's hematology tape you will know how much he stressed that B12 def can present with any neuro sign. that was his answer about how it will present.
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| darkhorse
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I need to see dr. fischer's note...what i know...patient can be asmptomatic....but there should be signs....here on examination there is no sign...any thoughts?
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| dudefop
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Hmmm.. I think hyperventilation can be the cause but still you'll need to check vitB12 level to be safe. Or at least you should warn the patient to check the level if the symptom persists or gets worse. You don't want to miss vitB12 deficiency.
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| deja_vu
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Cool doctor, vit-B12 def can cause any kind of neurological presentation BUT
Which has higher probability??
1) A vegetarian living in CA (not vegan as me007 said) developing some neurologic symptom due to B12 def which is in the form of Bilateral tingling in fingertips ONLY!! [nothing else] &&& only during the brief visit to high altitude area but not before.
OR
2) A classic presentation of respiratory alkalosis at higher altitude. [Pt is from CA visiting Colorado,Rocky Mt]
I think p(2)>>>p(1) in given situation. So don't waste money to confirm vitB12 and reassure.
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