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A few questions in the following case vignette. 1) What would you be concerned about without taking into account negative physical exam and studies? 2) In light of negative workup, what psychiatric diagnoses would you consider? 3) How would you break the news to her and what treatment?
I am thinking that she has some sort of somatoform disorder, possibly conversion disorder? brought on sub-consciously by the conflict with her son going off to college. Wanted to get your thoughts. Thanks!
You are working in a really busy emergency room and the following patient presents on an evening in May.
She is a 48 year old female who tells you that she has not been able to move her legs since this morning. She also notes that she has no sensation from her lower back to her feet. The onset of her symptoms was abrupt and she reports that she was having no problems the night before. She denies that she is in any pain. She denies that she has had any trauma to her head, spine, or legs.
Her past medical history is significant only for a hysterectomy three years ago for uterine fibroids. She does recall having a viral type illness with both upper respiratory and GI symptoms about 3 weeks ago. She did not seek care from a physician. She is otherwise in good health and is vigilant about routine medical care.
The only medication that she currently takes is hormone replacement therapy and a multivitamin. She is not allergic to any medications.
She has a family history of Type II diabetes in her father and hypertension in her mother.
She is a divorced mother of an 18 year old son who is about to graduate from high school and is planning to attend college out of state. She does remark to you, It would be awful, if I couldnt walk; he would probably decide not to go away to school. Im so proud of him. She has been divorced from his father since he was 2 and has never remarried. She has few significant social relationships and romantic relationships. She does not drink alcohol, use illicit drugs, or smoke. She has no past history of substance use or abuse, either.
On her physical exam, all findings are normal. Her neurologic exam is as follows:
Cranial Nerves are intact.
Sensation is intact in her upper body until a vague point distal to her umbilicus.
Her strength is normal in her upper extremities. She cannot move her lower extremities. Muscle tone is normal throughout.
Reflexes are normal in both her upper and lower extremities, including patellar and Achilles. Babinski is normal.
Gait cannot be assessed.
Cerebellar function is normal in the upper extremities.
CT and MRI of the brain and spine are normal.
All laboratory work (CBC, electrolytes, liver function, HIV, etc.) are normal.
Lumbar puncture is normal.
I am thinking that she has some sort of somatoform disorder, possibly conversion disorder? brought on sub-consciously by the conflict with her son going off to college. Wanted to get your thoughts. Thanks!
A Diagnostic Dilemma
You are working in a really busy emergency room and the following patient presents on an evening in May.
She is a 48 year old female who tells you that she has not been able to move her legs since this morning. She also notes that she has no sensation from her lower back to her feet. The onset of her symptoms was abrupt and she reports that she was having no problems the night before. She denies that she is in any pain. She denies that she has had any trauma to her head, spine, or legs.
Her past medical history is significant only for a hysterectomy three years ago for uterine fibroids. She does recall having a viral type illness with both upper respiratory and GI symptoms about 3 weeks ago. She did not seek care from a physician. She is otherwise in good health and is vigilant about routine medical care.
The only medication that she currently takes is hormone replacement therapy and a multivitamin. She is not allergic to any medications.
She has a family history of Type II diabetes in her father and hypertension in her mother.
She is a divorced mother of an 18 year old son who is about to graduate from high school and is planning to attend college out of state. She does remark to you, It would be awful, if I couldnt walk; he would probably decide not to go away to school. Im so proud of him. She has been divorced from his father since he was 2 and has never remarried. She has few significant social relationships and romantic relationships. She does not drink alcohol, use illicit drugs, or smoke. She has no past history of substance use or abuse, either.
On her physical exam, all findings are normal. Her neurologic exam is as follows:
Cranial Nerves are intact.
Sensation is intact in her upper body until a vague point distal to her umbilicus.
Her strength is normal in her upper extremities. She cannot move her lower extremities. Muscle tone is normal throughout.
Reflexes are normal in both her upper and lower extremities, including patellar and Achilles. Babinski is normal.
Gait cannot be assessed.
Cerebellar function is normal in the upper extremities.
CT and MRI of the brain and spine are normal.
All laboratory work (CBC, electrolytes, liver function, HIV, etc.) are normal.
Lumbar puncture is normal.
