Case Study: Leg Pain

[OVeractiveBrain]

Spinal tap, systemic angiogram, illiac lymph biopsy, and nerve conduction test. Just kidding.

Hes got an adult (late onset) form of muscular dystrophy. Just to make sure, his face isnt droppy is it?t Like it is melting? Cause if it is, hes got about 2 years max to live.

So far we've got Vitals, Meds, PMH, Allergies

Focused Physical exam and History on the legs, and a bit on general appearence:

Bilateral / Unilateral?

Trauma/ Critical Event at onset?

PMS present and quality?

Range of motion? Pain with extension, flexion, rotation, or just when standing on them?

General Appearence of legs, purple, swollen, edemic?

Spastic Contractions? Limp?

Numbness, Tingling, Pain in any other distal extremity?

Also: His chief complaint is the leg pain, right? Nothing else?

Bilateral DVTs in an active patient seems unlikely, and a lot of things can cause leg pain. Before I went down the OMG HES GOT DVTS AND IS GOING TO PE route, Id probably explore some neural stuff.

In particular, the movement of pain from hands to the legs is peculiar, and strikes me as something systemic and neural. Though the fact that it moved from his hands to his quads throws out half my impressions. If it were mainly in his ankles it sounds neurodegenerative, since its in his legs probably not.

While ODing on sympathetic agonists (like his puffer) could result in a diskinesia (feeling of needing to move around alot) actual pain shouldnt be felt. Especially since this guy is now at rest, and still has pain in his legs (i assume weve moved to the ambulance at this point, correct me if im wrong).

[ERDoc]

It looks as if a lot of people are thinking DVT. It should be on your differential, but keep in mind that it is very uncommon to have bilateral DVTs in healthy people (as Brain said). It is also unusual to have episodic exacerbations of the pain. The pain from DVTs is pretty constant and usually gets worse if you touch the painful area. However, DVT is one of those dx where if you consider it you need to rule it out. This is easily done with ultrasound. Has this patient done anything strenuous recently? Any recent medication changes? Any fevers or URI symptoms? Any h/o trauma? Any numbness or tingling? Any pain in the perineal area? Any problems with bowel or bladder incontinence?

[Dustdevil]

It looks as if a lot of people are thinking DVT. It should be on your differential, but keep in mind that it is very uncommon to have bilateral DVTs in healthy people (as Brain said).

Ooops! I missed the whole bilateral thing. :oops:

But it wasn't mentioned in the original post. :x

I'm going with PID. 8)

[fiznat]

So far we've got Vitals, Meds, PMH, Allergies

Focused Physical exam and History on the legs, and a bit on general appearence:

The pain is bilateral, there is no tingling of the extremities. Cincinnati stroke scale is zero, PMS/CSM is equal times 4 extremities.

The patient stands up to get into the stair chair even though we told him not to, and though there seems to be some pain, he does have full range of motion of all 4 extremities.

On palpation the muscles seem to be rigid. The patient says the pain comes all at once, then relaxes in waves. It sounds like muscle cramps the way he describes it.

It looks as if a lot of people are thinking DVT. It should be on your differential, but keep in mind that it is very uncommon to have bilateral DVTs in healthy people (as Brain said). It is also unusual to have episodic exacerbations of the pain.

I was thinking about these things as well. Still, there were other things I found that swayed my opinion. ...Things nobody has asked about yet :wink: Hint: it isnt anything exotic. Think about what we routinely check on all of our patients. Especially THESE kinds of patients.

Has this patient done anything strenuous recently? Any recent medication changes? Any fevers or URI symptoms? Any h/o trauma? Any numbness or tingling? Any pain in the perineal area? Any problems with bowel or bladder incontinence?

No strenuous activity/history at all. I asked a lot of questions about this kind of stuff and it appeared as if the patient is completely atraumatic. No numbess/tingling. No bladder problems at all, in fact the patient mentions that he has been urinating quite frequently.

I'm off to work till 2300 tonight, I'll check for replies when I come back. ...Just think about routine ALS-- the key to this is nothing exotic.

[medic001918]

I'd be curious about his blood glucose level and how well controlled his sugar has been. It could be some neuropathy setting in.

Shane

NREMT-P

[irme]

Skin tenting present? Not some kind of electrolyte imbalance caused by dehydration causing muscle spasms? Maybe increased hypernatremia?

[Code 8 Paramedic]

Underlying electrolyte imbalance is my guess. Does the pt have any signs of substance abuse?

[AnthonyM83]

What is the general appearance of his legs? Upon your palpation? Edema?

[fiznat]

I'd be curious about his blood glucose level and how well controlled his sugar has been. It could be some neuropathy setting in.

Shane

NREMT-P

Heeey now we're talkin!

The blood sugar reads at 400. When you get the readout, the patient looks at it and nods. "Yeah," he says. "Its been high all week." So high, in fact, that his home monitor wont even read it. Instead it has been simply reading "hi" for 7+ days.

The patient has stayed current with his bid (50u) insulin, but it doesn't seem to have helped.

Everyone is on the right track now... let's talk some pathophysiology. Why is he cramping, what kinds of things do we want to be aware of, and what can we do about it in the ambulance?

[vs-eh?]

Hyperglycemia = osmotic diuresis = pee pee = dehydration + hypokalemia?

His potassium was ummmm 3.1 mEq/L?

EDIT - The reason I had asked about hardcore "puffer" use before was that (s)albuterol can cause transient hypokalemia I believe on the order of reducing by 1.0 mEq/L? I don't recall...