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  #1  
Old 03-21-2012
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Unhappy Right Temporal Headache!

30 yr male complaining Rt temporal headache and Rt posterior neck, Rt upper limb numbness since past 2 weeks.. since last night the numbness involved Rt lower limb as well.

personal hx:
profession: computer engineer
hight 170 cm
weight 95.3 kg
diet vegeterian
non smoker, non alcoholic
No history of trauma.
No operative history.

family hx: mother HTN,DM
both grandfather had IHD ,died in their late 50s.

Vitals and investigations done:
blood pressure 116/72 mm hg
temp 36.7
pulse rate 92
Respiratory rate 18
SPo2 98

O/E
H: s1,s2, no murmur,regular pulse,jvpne
L: clear
A:no masses
CN grossly intact, no nystagmus or diplopia
no pronator drift
power 5 all limbs
reflexes 2+, planters downgoing
no dysmetria/dysdiachokinesia
Romberg's -ve
gait steady, abe to heal-toe walk
sensetion to pinprick diminished over Rt.posterior neck,Rt UL and RtLL(non dermatomal pattern)

Labs
wbc 10.04 high (3.40-9.60)
lymphocytes 3.71 high (0.94-3.08)
Glucose POCT 7.3 high (3.0-6.0)

electrolyte,urea,creatinine,GFR folic acid, B12, free thyroxin and TSh within normal range

CT brain and cervical x-ray- No abnormalities detected.


What is the most likely diagnosis for this pt and why?
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Old 03-21-2012
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Symptoms are of neurological origin and seem to be ipsilateral. All the tests and organ systems are normal except for his Labs - WBC, Glucose and Lymphocytes are all increased.

My Differentials would be -
1) Migrain or Cluster Headaches
2) B12 deficiency (hes vegetarian)
3) Somatization disorder (probably not)


Not sure, Is this a USMLE Question? What are the options if any?

Last edited by Hope2Pass; 03-21-2012 at 10:45 PM.
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Old 03-21-2012
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It can be a sign of neurodegeneration of dominant hemisphere.
but in dat case it has to show on MRI

BUT i have seen such cases before the patient MUST be abusing a substance or on a TCA or any other neuro drugs. Its a side effect of drug
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as B12 done in blood report is normal. so we omit that option from what have suggested. no its not usmle question!
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Quote:
Originally Posted by bunny View Post
It can be a sign of neurodegeneration of dominant hemisphere.
but in dat case it has to show on MRI

BUT i have seen such cases before the patient MUST be abusing a substance or on a TCA or any other neuro drugs. Its a side effect of drug
yeah Bunny thanks for your opinion but pt has no such history for sure. any other guesses?
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Old 03-21-2012
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than my best guess is Syringomyelia
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He is overweight and his BMI is more than 30 and glucose little higher than it should be.. does this give any such symptoms which pt has?
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Syringomyelia is can be due to trauma
he is computer engineer using computer for long times can damage the spinal cord & its nerves

and in Syringomyelia patient starts from headache and then progress loss of function ensues starting from top to bottom
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Quote:
Originally Posted by oksana View Post
He is overweight and his BMI is more than 30 and glucose little higher than it should be.. does this give any such symptoms which pt has?
Diabetic patient with poorly controlled diabetes ?
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Quote:
Originally Posted by Hope2Pass View Post
Diabetic patient with poorly controlled diabetes ?
This is first time during hospital visit high glucose is detected his last visit for regular whole body screening was just before 3 months that time sugar was normal... so we can not say diabetic..
I guess it might be stress diabetes? isnt it?
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Quote:
Originally Posted by bunny View Post
Syringomyelia is can be due to trauma
he is computer engineer using computer for long times can damage the spinal cord & its nerves

and in Syringomyelia patient starts from headache and then progress loss of function ensues starting from top to bottom
Bunny ,I am also thinking over the thing you have suggested.
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i dont think so he may have eaten something in the hospital before the test :P

btw mother is diabetic doesnt predispose him to DM
he is a vegetarian it means he is very concious about his health
cholesterol levels are normal it means he is aware of some physiology of what his parents had

just a guess but DM neuropathy doesnt cause headaches and then progressive loss of function

i will stick to syrinomyelia until proven otherwise
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Yeah I am leaning towards Syringeomylia as well now. The cape-like pattern of symptoms described is characteristic of it too. May be an MRI would confirm that lol

For reference -
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002373/
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Old 03-22-2012
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Guys, I know this is not usmle question but after 73 visitors only 2 care to give suggestions/opinions. I know everybody very busy with exam preparation and so I am. but this is real important case for me..
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Old 03-26-2012
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He had visited neurologist.His neurological examination was normal. Doc has prescribed some blood test(Fasting glucose,ESR and ANA) and advised for cervical and brain MRI,EMG study(appointment is given for 23 may 2012).
I will keep updating the details in case anybody is interested to closely follow the case..

Thanks!
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