The unusal presentation

Hi guyz,

I’m in my 2nd week of neuro placement. I have a patient that I thought would be interesting to share about. So the information is as follows…

PHx: Was hit by an object in the face. A few days later presented with fluid coming out from the ears and had a salty taste down the back of throat. Saw GP--> CT head= cribriform plate #--> immediately admitted to the hospital. Stayed in hospital for 4 days-->NAD-->flown back home. Suffered severe headache & occ rhinorrhea still and worsening of gait and coordination. Has pre-existing symptoms of ® UL& LL hemiparesis, sensory deficits & ataxic gait.
PMHx: in ’05, first episode of severe headache. Began with fooginess of ® eye-->® cervico-occipital headache which radiated to frontotemporal region, lasted 2hrs. Was diagnosed with migraine. Has nil previous hx of migraine or family hx of migraine. 2nd similar episode in early ’06, but this time was assoc with ® hemiparesis & sensory deficits. Deficits never resolved. In all, had 4 episodes last yr. Nil neuro diagnosis was ever made.
SHx: lives alone. Works underground, was able to continue working despite deficits as was able to "hide" them.
Inx: MRI Cranial/ spinal cord—nad; CT head—nad; Lx puncture—nad, just ↑glucose of CSF; Indium scan: nil CSF leakage

S/E: c/o pre-exisitng weakness & sensory loss & clumsiness with gait got worse when was flown back home. Has increase headache with movements of limbs. Headache =6-8/10
O/E:
· CN III, IV, VI — nad. Eyes tracking√
· Gowlands stage of recovery— ®arm: stage 5; hand: stage4; leg: stage 5; foot: stage 4
· Ms strength— UL: ® Gr 3-4; (L) Gr 4-4+
LL: ® Gr 3-3+; (L) Gr 4-4+
(Had increase in headache with mvts of limbs, ? true strength)
· Sensation—Light touch: UL: ® ↓↓ palmer> dorsum of hand. ↓ lateral aspect> medial aspect of hand/ forearm/ arm (i.e. feels more on C8, T1 dermatomes). (L)↓ palmer surface of hand.
LL: ® plantar surface nil sensation. ↓on dorsum of foot. ↓ant surface> post surface of lower leg/ thigh (i.e. feels more on L5, S1, S2 dermatomes). (L) ↓plantar> dorsum surface of foot.
Sharp/blunt: ® UL& LL: absent. (L) UL/LL: ↓ (5/10)
Joint position/ jt mvt sense: ® big toe/ ankle—able to det mvt but not direction. (L) big toe/ankle—able to det mvt. Direction 6/10. very slow response. Knee & hip jts not tested yet.
· Sitting posture: slightly W.B on (L)> ®
· Sitting Balance: Static √
Dynamic—Int disp: √ ; Ext disp: slight ↑ resistance when disp to the ®. Efficient saving response. Safe in static & dynamic sitting.
· Standing posture: slight W.B (L)> ®. Tunk tone (L)=®
· Standing Balance: Int disp: slight ↓ to ®. AP/PA√. Tend to overestimates ability but able to recognize when told abt safety.
Ext disp: uses a stepping response for slow & fast disp. (i.e. when disp to ®, ® foot steps out to the ® instead of (L) foot crossing over to take a step to the right).
Safe in standing, static & dynamic.
· Balance: feet tog, EO=30s; EC=5s
Sharpened Rhomberg, EO, (L) fwd= 8s, ® fwd= 11s
SLS, EO, (L)=25s, ®=5s
· Gait: -↓ ® heel strike on initial contact
-® knee hypertext during loadingàmid-stance
-↓ hip E during mid stanceàtoe off
-↓wt transfer (pelvis lat shift) during mid-stanceàtoe-off
-↓ knee F when hip in E during swing phase

So far, what I’ve been able to do is part Ax with the patient each session as I did not want to aggravate his headache too much.

With no neuro diagnosis to be made and with a unique presentation of sensory loss deficits (e.g. deficits of L5,S1, S2 more than L1,2,3; deficits on bilateral limbs), I was quite thrown away by that. Besides, the weakness presented does not match the deficits in sensation. According to my supervisor, the presentation of the patient is unusual. The stepping response during external displacement in standing is also not the norm. She suggested for me to keep these unusual presentation at the back of my head and not to worry too much about it. She advised me to just address the problems like I’ve been taught to, and with more experience in future, I would be able to recognise the abnormal from the norm.

So I’ve been trying to put those doubts aside first & deal with the problems that I can address first. I’ve been working (2 sessions) on weight transference in standing, as well as gait re-edu. I’ve also gave pt some ex’s to improve vol. mvts e.g. DF with knee extension fr 90deg flx to 0deg ext. Pt appeared to have better gait (↑ heel strike) after each session. However, my supervisor thinks it is unusual for the pt to have that much of an improvement after each session.

Thoughts for this week: it is a skill to note the subtleness of abnormality from the normality, the unusual fr the usual. How do we know how much can the patient improve and if it is unusual or not?
Anyone has any thoughts with regards to Ax/ analysis/ Rx of this pt?

Sorry about the long blog. Hope I didn’t confuse anyone.
Have a great week ahead!