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

Relevant History:

• What level and subtype of spina bifida does the patient have? How has it been treated in the past? Is there a ventriculoperitoneal shunt and history of hydrocephalus?
• What was the patient’s birth history and neonatal course?
• How long has this been going on?
• Has this ever happened before?
• Describe the urinary incontinence episodes and how they occur. Does the patient have the sensation of bladder fullness typically? How about now?
• Does the patient have a spastic (upper motor neuron) or flaccid (lower motor neuron) bladder?
• What is the patient’s usual urinary continence regimen? Does she self-catheterize? What are her typical urine volumes? How often does she catheterize per day?
• Are there any other symptomatic changes, including bowel function, strength, sensation, headaches, nausea, muscle tone, vomiting, pain, posture, vision/hearing, cognition, memory?
• Any functional changes? What is the patient’s baseline and current functional status?
• Has she sustained any falls?
• What equipment does the patient require? How is the condition of this equipment?
• How was/is school? What grades did the patient receive? Is she studying in postsecondary education, or has she in the past?
• What is the patient’s social history and work status? Does she live with anyone else?
• Full past medical and surgical history?
• Medications?
• Allergies?

Relevant Physical Examination:

• Vital signs
• Cranial nerve testing
• Orientation questions
• Observation
• Range of motion, muscle tone analysis
• Manual muscle testing, sensation, reflexes of bilateral upper and lower limbs
• Gait, if applicable

+ What is your differential diagnosis for her changes as described?

• VP shunt malfunction, hydrocephalus, Chiari malformation, tethered cord, cervical myelopathy, stroke, cervical/thoracolumbar spinal stenosis, cauda equina syndrome, syringomyelia, urinary tract infection.

+ What steps would you take to help narrow down your differential diagnosis?

I would order the following tests:

• CT scan of brain, cervical spine, thoracic spine, lumbar spine
• Urinalysis +/- urine culture
• CBC (complete blood count)
• CMP (complete metabolic profile)

+ Your workup reveals the following:

• Imaging of brain/spine: ventriculomegaly, increased from prior scans
• Urinalysis: yellow color, clear turbidity, negative leukocyte esterase, 2 white blood cells per high powered field
• CBC/CMP: normal

+ How would you manage this patient?

• I would arrange for the patient to proceed to the emergency department immediately. I would call the ED and discuss her case with the ED physician and advise a stat neurosurgery consult, as the patient likely has hydrocephalus as a result of VP shunt malfunction. I would counsel and educate the patient on the rationale for these steps, the diagnosis, and the likely need for surgical intervention.

+ If the patient were to strongly oppose receiving a CT scan due to the exposure to ionizing radiation, how would you proceed?

• First I would counsel the patient on the risks and benefits of obtaining a CT scan against the risk of disease progression, continued and permanent functional loss, and death with delay of care. Second, the patient has an existing VP shunt in place. I would need to quickly confirm whether or not her VP shunt is MRI-compatible by asking if she carries any information with her regarding her specific device brand, name, and model. She may also have a company representative that I can call to see if they are available for quick answer. After calling for assistance in transporting the patient promptly to the emergency department, I would attempt to quickly search for a product information page on the company website to determine whether or not her model is MRI-compatible. If I could find no immediate answer, I would counsel the patient that the CT scan is in her best immediate interest despite the exposure to ionizing radiation.

+ What is your response?

• I am so glad to see you doing better! You had a serious situation going on at the time, so I am just glad we were able to get you help quickly. I know you mentioned you have not had any accidents lately, but I am concerned about the bruising I see on you. I want to make sure you and all my patients are safe. Do you feel safe at home and at work?

+ The patient responds:

• Actually, I’ve kind of been dealing with some issues with my boyfriend. He’s thrown a couple of dishes at me. It’s ok, though, he doesn’t mean to hurt me, it’s just “couples” stuff that happens in any relationship.

+ Your response?

• I am so sorry to hear about your issues with your boyfriend. That can be incredibly difficult for anyone. However, I am concerned about your health and safety. It is not normal to be hit or struck in any healthy relationship. We need to ensure your safety. Please allow me to provide you with resources to achieve this end, including arranging for a safe space for you to live (whether that’s your current home or another location), and proper involvement of the authorities regarding your boyfriend. I will get in touch with a social worker and help to provide you with social services to achieve these goals. Please allow me to work on this for you. In the meantime, you are safe and free to remain here. I am more than happy to discuss my thoughts further with you. I know that this is incredibly difficult, and that what you have been enduring is likewise incredibly difficult. I am here for you. What questions or thoughts do you have for me at this moment?

• Note: The goal is to separate the patient from her abuser while providing social services for her and involving the appropriate authorities in this case.