Leg Pain

Chief Complaint: A 63 year-old male presents with acute onset left lower extremity pain with numbness.

DOMAIN A: DATA ACQUISITION

+ What are the key components of this patient’s history and physical examination?

Relevant History:

What is the onset, timing, exact location, duration, aggravating/alleviating factors, ?radiation, severity of the pain and numbness?
Was there injury or trauma?
Has this ever happened before?
Any back pain, neck pain, swelling, skin changes, fever, chills, vision or hearing changes, nausea, weakness, gait or balance problems, bowel/bladder changes?
Has he had any workup or treatment so far for this problem?
Past Medical/Surgical History?
Family History?
Social History?
Functional History? Current functional status?
Medications?

Relevant Physical Examination:

Vital signs
Inspection
Palpation
Range of motion of cervical and lumbar spine, bilateral lower extremities
Cranial nerve examination
Manual muscle testing, reflexes, sensation testing of bilateral upper and lower limbs
Special testing: Babinski, Hoffman, Straight Leg Raise, Slump Sit, Femoral Nerve Stretch Test, Tinel at inguinal ligament/fibular head/medial malleolus

+ Challenge Question

Explain the femoral nerve stretch test and how you would perform it.

+ Challenge Answer

The femoral nerve stretch test is a test similar to the straight leg raise, only more specific for the upper lumbar nerve roots (L2-L4). The examiner performs the test by having the patient lying prone, allowing the examiner to then flex the knee of the affected limb beyond 90 degrees while extending the affected hip. If reproduction of radiating leg pain occurs with this maneuver, the test is positive and indicates a possible mid-to-upper lumbar radiculopathy or femoral neuropathy.

DOMAIN B: PROBLEM SOLVING

The patient is a 63 year-old male with a history of type 2 diabetes mellitus who presents with a 1-week history of sudden-onset constant, burning left lower extremity pain in the anterior thigh, posterior thigh, and medial leg below the knee with numbness and tingling in this distribution. He is functionally independent. On exam he demonstrates intact strength and reflexes of the bilateral lower extremities with impaired sensation in the left lower extremity in his anterior and posterior thigh and medial leg below the knee.

+ What is your differential diagnosis for this patient?

Lumbar radiculopathy, sacral radiculopathy, lumbosacral plexopathy, diabetic radiculoplexopathy/diabetic amyotrophy, femoral neuropathy, sciatic neuropathy, cervical myelopathy, stroke (right anterior cerebral artery), Guillain-Barre Syndrome/AIDP, CIDP, amyotrophic lateral sclerosis (ALS), PLS, diabetic peripheral polyneuropathy, femur/hip or pelvis fracture, polymyositis.

+ The patient notes a 30lb weight loss recently along with a hemoglobin A1C of 8.3%. What is the most likely diagnosis?

Diabetic radiculoplexopathy/diabetic amyotrophy.

+ The patient is diagnosed with diabetic radiculoplexopathy/diabetic amyotrophy. How would you proceed with workup?

I would order a complete blood count (CBC), erythrocyte sedimentation rate (ESR), hemoglobin A1C, EMG left lower extremity, and MRI lumbar spine and left lumbosacral plexus.

+ Workup reveals the following:

CBC: normal
ESR: elevated
Hemoglobin A1C: 8.3%
MRI lumbar spine and left lumbosacral plexus: increased signal in L2-L4 nerve roots and lumbosacral plexus.
EMG/NCS left lower extremity: decreased amplitude of sensory nerve action potentials (SNAPs) and compound motor action potentials (CMAPs) of left tibial and fibular/peroneal nerves. Fibrillations and positive sharp waves present in left rectus femoris, semimembranosus, gastrocnemius, and tibialis anterior with rapidly firing voluntarily recruited motor units in this musculature.

DOMAIN C: PATIENT MANAGEMENT

+ The diagnosis of diabetic radiculoplexopathy/diabetic amyotrophy is supported with your recent test results. How would you proceed with management?

I would educate the patient on the diagnosis. I would counsel that this condition can be particularly painful, but can be treated with neuropathic pain medications such as gabapentin, pregabalin, amitriptyline, nortriptyline, duloxetine, or venlafaxine. I would advise he monitor his functional status closely as we treat his pain. I would educate that prognosis varies from person to person in terms of pain and functional recovery, but weakness can develop which can affect his function. I would ensure that all questions are answered and that the patient is in agreement with the plan.

DOMAIN D: SYSTEMS-BASED PRACTICE

The patient returns to clinic 2 months later and notes that he is falling down repeatedly at home. He is not using an assistive device. He has bruising on his arms and legs. He feels fatigued. Exam reveals unsteady gait requiring him to lean against the wall for support; he demonstrates 2/5 strength throughout the left lower extremity.

+ What would you advise at this point?

I would recommend x-rays to ensure no fractures are present from the falls. I would inquire as to whether the patient lost consciousness, felt lightheaded, or struck his head at all. I would ask about any changes regarding, weakness, numbness, tingling, or pain. I would discuss hospital admission for further workup of his falls and fatigue.

The patient is admitted to the hospital. X-rays reveal no fractures; however, he is discovered to have sustained a retroperitoneal hematoma compressing his left femoral nerve; the hematoma is evacuated. His hemoglobin is 7.6 g/dL. and his blood sugars average 220-250 mg/dL. Physical and occupational therapy evaluations reveal the patient to be functioning at a moderate assistance level. You are consulted to provide rehabilitation recommendations.

I would recommend inpatient rehabilitation admission.

The patient’s insurance company denies inpatient rehabilitation admission, citing that his medical needs can be met at a lower level of care.

+ How would you proceed?

I would call a peer to peer discussion with the insurance company to explain why the patient should qualify and be approved for IPR. I would note that the patient’s hemoglobin of 7.6 is dangerously low and requires daily medical monitoring to ensure he is not further bleeding into his retroperitoneum or elsewhere, as this risks further nerve dysfunction, organ damage, and death. He requires active management of his diabetes as well, which is not controlled, along with dietary counseling and weight management strategies long-term. He may require insulin, and thus nursing education on how to perform insulin injections and monitor his blood glucose at home. We will actively manage his pain medication and find him a balanced regimen that successfully and consistently treats his pain on an outpatient basis. Finally, his functional level is well below his baseline of independence, and requires 5x/week of physical and occupational therapy to regain functional independence. All of these problems cannot be met at a lower level of care.

Your peer-to-peer call is successful, and the patient is approved for inpatient rehabilitation admission.

DOMAIN E: INTERPERSONAL AND COMMUNICATION SKILLS

You are rounding on this patient during his inpatient rehabilitation stay. He is functionally improving and enjoying pain relief with gabapentin. He stops you before you leave his room to see other patients. Pretend that I’m the patient. This is our role-playing portion of this case.

Patient: “Oh, please, stay! Let’s pray together. You have been such a blessing and I want to express my thanks for your care with you alongside me.”

+ Will you join me in prayer?

This scenario is a sensitive issue, often for both parties. We do not have a templated example response, as proper responses to this scenario can widely vary. In its simplest form, this scenario reflects a grateful patient simply expressing his or her gratitude for your care. The correct answer is to respond in a manner that is consistent with your own belief system, but also promotes harmony, trust, and an ongoing positive relationship between you and your patient. If you are not religious or you belong to a different religious belief system from the patient, it is reasonable to state this or politely decline their offer as long as you ensure you do not offend or demean the patient in any way. Make sure to demonstrate respect for the patient’s belief system. If you do or do not share the patient’s belief system, but would be happy to pray with the patient, then it is also reasonable to do so as long as you feel comfortable with this and do not neglect your other patients in any way. Ultimately this is usually a kind gesture of thanks from a grateful patient, so don’t sweat it!