Medical Student Challenge #2 of 4

The Doctor Game- Test Yourself

 

Are you a medical student or a resident? Do you want to try to figure out the diagnosis? Below is a challenging patient case.  See if you can solve the case.  Send in your diagnosis to nonclinicaldoctors.com

 

A 67-year-old female comes to the urgent care because she fell in the shower 3 days ago and now she has head pain. She has had non-insulin dependent diabetes for about 20 years and it is not always well controlled.

She has mild renal failure. 

 

She is complaining dizziness, trouble with coordination and tingling of the left foot that started some time after she fell, but not on the day she fell. She has been sleeping well since she fell and she hasn't had a change in appetite. She doesn't usually drive because her vision is not good. Her son drove her to urgent care center today. She had not been planning on coming in for a medical evaluation, but when her son stopped by to visit her at her home, he noticed a bruise on her forehead. When she told him about her falling episode that occurred in the shower, her son became concerned and wanted her to be evaluated. 

She lives by herself. She has 3 adult kids on the area and she relies on them for driving. She used to work as a cashier and retired 2 years ago. Her son says that her health seems to have deteriorated after her retirement. She generally goes out to do errands about 2x per week and rarely gets out besides that.

She is not physically active. She used to go to church but stopped around the time she retired. 

She used to smoke 1 pack of cigarettes per day, and quit about 10 years ago. She used to drink in moderation and no longer drinks at all.

 

Physical examination

Appearance- she has a large bruise on the left side of her forehead and what appears to be a healing superficial wound without any deep cuts.

The wound does not appear infected. There is a small bump.

Blood Pressure is 140/75

Heart rate and rhythm are regular. There are no murmurs 

Carotid examination- no bruits

Lungs- breathing rate is normal. Breath sounds are clear 

Abdominal examination- demonstrates a soft abdomen with normal bowel sounds. There are no lesions and there is no tenderness.

Skin appears normal 

Pulses are diminished in her lower extremities and normal in her upper extremities.

Neurological examination:

She is awake and alert and oriented x 3.

She has mildly slurred speech. Her language and comprehension are normal.

She does not demonstrate any facial asymmetry. 

Extra ocular movements are intact with no nystagmus. 

Pupils are equal, round and reactive to light. There are no signs of bleeding or trauma to her eyes.

Her funduscopic examination is normal.

Her hearing examination is normal and there are no signs of trauma to her ears.

 

She has decreased sensation to light touch, pinprick, temperature and vibration of the left foot and leg.

She has normal sensation of bilateral upper extremities.

She has brisk reflexes of the right lower extremity and decreased reflexes of the left lower extremity. She has normal reflexes of bilateral upper extremities. 

Her strength is decreased in the left lower extremity and mild decrease in the right lower extremity. She has normal strength in bilateral upper extremities. 

Her coordination is slow but accurate. She demonstrate normal rapid alternating movements if her upper extremities. She demonstrates mild dysmetria on finger to nose evaluation. 

Her gait is normal when walking. Romberg is positive (she is unable to stand straight with both feet together) and she is off balance when asked to walk heel-to-toe.

 

What do you think is wrong with this patient? Do you think you should order any diagnostic imaging or blood tests and, if so, which ones? 

*If you like The Doctor Game, see the previous medical student challenge*

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