2005 Exam I Case 03

Chief Complaint:

A 71 year old, right-handed, diabetic male with back pain and weakness.

History of Chief Complaint:

He presented by ambulance to the emergency room complaining of two days of intermittent severe low back pain radiating into his legs and bilateral leg weakness.  While sitting in the emergency department awaiting examination, the patient experiences a severe episode of unremitting low back pain and currently cannot move his legs and has become incontinent for bladder and bowel.

Medical History:

The patient has a long history of hypertension and uncontrolled diabetes mellitus.  He states he was prescribed some medication by his primary care physician 5 years prior, but he used it all up in one year and assumed that meant he had completed the medication course.  Recently, he was diagnosed with an abdominal aortic aneurysm. 

Review of Systems:

He admits to having poor vision and poor feeling in his feet prior to this recent event, but denies having any prior incontinence of bladder or bowel.

General Physical Exam:

The patient is awake and oriented to person, place and time.  He is in acute distress.  He is a well-nourished man who appears older than his stated age.  Fundoscopic exam revealed microaneurysms and microhemorrhages along with cotton wool patches on the retinal surface.  Tympanic membranes are intact and uninflamed.  Pharynx is non-reddened.  Blood pressure was elevated at 180/100, heart rate was 82, respiratory rate was 20 and temperature was 97.50F.  His heart has a regular rhythm and rate and chest was clear to auscultation bilaterally.  Peripheral pulses were absent at ankle and wrist. Abdomen was soft with no tenderness, lumps or masses.  A small ulcer was present on the medial side of his left foot.

Neurological Exam:

Mental Status: Patient is extremely anxious.  Memory and knowledge are appropriate for age.  Speech was articulate and meaningful.  He could follow three and four-step commands.

Cranial Nerves:  External ocular muscles are intact and pupils are round and reactive to light and accommodation.  Visual fields are full to confrontation; visual acuity is poor bilaterally.  Hearing was diminished bilaterally to finger rub.  Sensation on face was intact.  Facial expressions were full.  Gag reflex was present and tongue protruded midline.

Motor: Upper extremity strength was 5/5 bilaterally.  Lower extremity strength was 0/5 at the thigh, hips, knees and ankles bilaterally and demonstrated no resistance to passive range of motion.  Deep tendon reflexes were 2/4 bilaterally in upper extremities and 0/4 bilaterally in lower extremities.  He was incontinent of both bladder and bowel.

Sensory: Patient was unable to feel pinprick or thermal sensation bilaterally below T12 dermatome.  Two-point discrimination, position and vibratory sensation were intact throughout his body with the exception of a mild diminution about the wrists and ankles bilaterally.

Follow-up:

Six weeks following the ER visit, the patient demonstrated bilateral hypotonia about his hips, knees and ankles.  Significant muscle atrophy was present throughout both lower extremities.  Pinprick and thermal sensation remain absent in the lower extremities.  He had vibratory sense on his shins, but it remained suppressed about his wrists and ankles.  He continually dribbled urine with no control and had a residual volume of urine in the bladder at all times.