New Quickie Case

[jmj11]

I saw a 67 year old woman one week a go with a gradual onset and worsening of 1) low grade daily headache, 2) feelings of dizziness, 3) imbalance, 4) electric-type shocks down the right side of her body

 

The earliest record I can find of these symptoms (in her PCP notes) was 2006 when she presented to the ER with the same and had a normal CT scan.

 

PMHx: generalized anxiety disorder for years.

 

Dx: by pcp, 1)Anxiety and stress headaches.

 

On my ROS I will add + urinary incontinence and + memory loss.

 

Exam: normal except a slow and wide stance on her straight away gait, tandem with difficulty and neg Romberg.

 

Any questions? Anyone want to buy a vowel? Anyone want to solve the puzzle?

[rcdavis]

at first glance, sounds like normal pressure hydrocephalus... but the right sided pareasthesias are not in the usual presenting sx for that dx.

 

having made that as a working dx, my next step would be to do a further hx and pe,

 

any tick bites, and sx dementia other than the memory loss?

 

what kind of memory loss... remote, recent, global?

 

any cognitive defects?

 

Any speech deficit?

 

Is she a drinker or user of chronic medications/ herbals? (lexapro, commonly used for dewpression and anxiety) can give a BUNCH of weird neurologic side effects)... any medications taking which need levels?

 

Has she had an MRI with any placques or lesions s/o ms or amyloidosis?

 

Any visual defects of sx such as diplopia/ peripheral vision deficit?

 

any weight loss? any weakness or AM fatigue?

 

any skin lesions or muscle wasting?

 

Any festinating gait?

 

Difficulty getting out of a chair? Difficulty or change in handwriting?

 

gotta pt...

 

Back.

 

Any sensory LOSS?

 

is she a vegan?

 

Any past exposure to heavy metals? Welder?

 

Any gi complaints? Loss of appetite?

 

Except as specifically above, did you happen to notice the mucosa of the tongue.. Was it normal? Tongue size normal? Any skin pallor, abnormal nails ( spooning, creases, lines? ). Vibratory sense normal?

 

Finger nose, proprioception and heel shin normal?

 

Mental status exam normal?

 

Then, unless something clinches the dx on PE,

I guess CBC, TFT /TSH, RPR, bmp, UA, b12/folate, and repeat CT head looking for ventriculomegaly or Arnold chiari malformation

 

Further exam based on results on above

[jmj11]

at first glance, sounds like normal pressure hydrocephalus... but the right sided pareasthesias are not in the usual presenting sx for that dx.

 

My thoughts exactly.

 

My answer to all your other questions is no . . . and the memory is short term, mild. She scored 7 in naming zoo animals in 1 minutes (mild cognitive survey) with >12 normal, but 32 out of 32 on my mini mental status exam.

 

I order an MRI on the first visit . . . she didn't do it because of cost. I order labs including sed rate CBC, folate and were normal.

 

I re-ordered the MRI on the second visit.

[jmj11]

File removed

[Sara Wajek]

You might want to remove the patient's info from the last pic you posted.

[rcdavis]

Okay, I guess no one else is gonna have a go at it.

 

There appears to be an isodense mass just to the RT of the pons and compressing the pons and some of the 4th ventricle, which may explain the ventriculomegaly.

 

There is also loss of tissue just at the RT pre central gurus which May be an old RT parietal cortical infarction.

 

My primary concern is that this may not be a benign nph but a hydrocephalus due to the compressive lesion.

 

I am now at the limits of what I can do without some guidance as to what the pathology is... Is it solid as I suspect, or vascular?

 

I think at this point I would want a formal radiology read so I can ascertain whether this is a neurosurgical case or not.

 

And would probably stop the midrin or Xanax or whatever the fp has her on for stress.

 

Also.. She does have spontaneous venous pulsations and sharp discs, doesn't she?

[jmj11]

You might want to remove the patient's info from the last pic you posted.

 

Holy crap I don't know what happened. I cropped all that off. I double checked it on my computer and you couldn't see anything.

[jmj11]

Okay, I guess no one else is gonna have a go at it.

 

There appears to be an isodense mass just to the RT of the pons and compressing the pons and some of the 4th ventricle, which may explain the ventriculomegaly.

 

There is also loss of tissue just at the RT pre central gurus which May be an old RT parietal cortical infarction.

 

My primary concern is that this may not be a benign nph but a hydrocephalus due to the compressive lesion.

 

I am now at the limits of what I can do without some guidance as to what the pathology is... Is it solid as I suspect, or vascular?

 

I think at this point I would want a formal radiology read so I can ascertain whether this is a neurosurgical case or not.

 

And would probably stop the midrin or Xanax or whatever the fp has her on for stress.

 

Also.. She does have spontaneous venous pulsations and sharp discs, doesn't she?

 

Now that I've spent the last 30 minutes deleting those . . . and can return to the questions. You know her disc margins were fine. I didn't see SVP, but often I don't in healthy people. I've had discussions with the neurosurgeon and we did MRI with contrast and we are confident that this lesion is benign, but space occupying and causing problems. He suspects a meningioma. I think the location could account for the electric shocks she has been feeling. The gait, memory and other issues from the corresponding hydrocephalus.

 

I think the lesson is that when anxious people have new symptoms . . . they still deserve to be investigated.

[jmj11]

On more interesting thought. I spoke both to the neuroradiologist and neurosurgeon since I posted above. Both are now convinced that they lady has two unrelated processes, the mass (which may be coming off the 6-7th cranial nerve) and hydrocephalus. So symptoms of gait disturbance and headache related to hydrocephalus and the body electric shocks (and possible headaches) related to the brainstem mass effect. Case closed. All photos deleted from flickr.

[jesscbv]

rcdavis: Why would you want to know if she is a vegan? (I'm a pre-pa student, struggling to follow along.)

[Sara Wajek]

rcdavis: Why would you want to know if she is a vegan? (I'm a pre-pa student, struggling to follow along.)

 

I'm still pre-pa also, but I'm guessing they were concerned about a B12 deficiency. Since there are no plant sources of B12 (that I'm aware of) it's a common problem with vegans that don't take supplements.

[rcdavis]

Exactly. There is still one other teaching point, now difficult to show as mike had to pull the MRI, and that is that the mental status changesvwere not from the nph nor the mass lesion, was probably from the parieto-temporal old infarction.

[jesscbv]

Thanks Sara!

[jmj11]

Exactly. There is still one other teaching point, now difficult to show as mike had to pull the MRI, and that is that the mental status changesvwere not from the nph nor the mass lesion, was probably from the parieto-temporal old infarction.

 

I'm not sure I agree. I realize that the image wasn't stellar once I "printed it file" then attempted to crop it (but obviously failed) removing vital info. While there were some spotty nonspecific deep white matter changes, I didn't see an infarct (when I get the chance I will go back and look at the whole montage and see if you are seeing something I didn't notice). The neuro radiologist didn't see an infarct (at least didn't mentioned it in his report). I spoke to two neurosurgeons, one in Bellingham and one at Swedish in Seattle (where she is having surgery for the lesion in two weeks). Both agree that the gait, headaches and subtle cognitive changes are related to the hydrocephalus. If removing the mass doesn't change the symptoms, she will be shunted later.

 

My major caveat in this story is 1) if someone develops a new daily headache, you should worry a little. If that person is over age 50, you should worry more. If they are over 65, you should loose a little sleep. If they have other neurological symptoms, gait change, incontinence, cognitive changes . . . then YOU should be incontinent. Lastly, don't let an old CT brain give you a false sense of security. When these symptoms first started 2 years ago, she had a normal (generous ventricles) in the ER. She had a long history of anxiety so it was easy for the PCP to dx her as "tension, stress headaches" what ever the hell that is (not in the current headache classification by the International Headache Society). All crazy people eventually died from pathological disease. She wasn't even "crazy" but had some generalized anxiety.