A*******s
发帖数: 9638 | 1 This is a thread posted by a PCP at a physician forum, I find it is very
interesting. I posted my answer there, which was not listed on the
differential diagosis. Someone replied back to me and said it was helpful.
What do you guys think?
"I saw a patient today who (at facility #1) received 2 IM injections for the
patient's migraine: Toradol in one buttocks and phenergan in the other side
.
Pt states immediately after getting the Toradol she felt a severe pain and a
shock like sensation down the back of her leg. The patient then noted that
s/he couldn't move their own toes or dorsiflex the ankle. The patient
called facility #1 back and they said wait for an hour and then it will get
better, an hour later it was not and there was a return call to the facility
and they said wait a day.
One or two days later the patient went to the ER at facility #2, and was
given a walking boot and crutches and told to see the family doctor.
On my exam (now this is facility #3) there was sensation intact on the leg
and foot, hyperasesthia on the lateral portion of the foot, no sensation on
the great toe, and no movement at the toes or the ankle, there was also loss
of position sense of the toes.
I told the patient that a consult with a neurologist is important at this
point, I asked for the soonest appointment with facility #2 (the only one of
the three with neurology department) and the soonest is in August. I also
said keep in the boot as much as possible to keep the ankle joint position
at 90 degrees.
Patient happens to be a nurse and thinks the shot was given in the wrong
location. The patient asked me if this will get better, I said only time
will tell.
I tried to be very careful not to joust facility #1. I only said, I think
this is a nerve problem and you need to get a consultation with a neurolgist.
Any other suggestions? " |
A*******s
发帖数: 9638 | 2 Everybody there is talking about a lawsuit. |
N*G
发帖数: 217 | |
A*******s
发帖数: 9638 | 4 Right side which got the Toradol.
【 在 NGG (梦想成真) 的大作中提到: 】 |
N*G
发帖数: 217 | 5 I would suspect the local nerve injury (sciatica N.?) first, may due to 1.
phenergan severe chemical irritation or even gangrene
2. compartment syndrome
3. directly N, damage
Also, I may keep in mind if it would be coincidence of systemic problems,
like MS?
As a PMD, while awaiting for neuro consult, I would order MRI of lumar spine
and pelvic and right LE. Further EMG and nerve conduction study may be done
by neurologist.
What did you say? |
A*******s
发帖数: 9638 | 6 I think what you’ve said is reasonable。 Any other thoughts?
I'll post my diagnosis tomorrow.
spine
done
【在 N*G 的大作中提到】
: I would suspect the local nerve injury (sciatica N.?) first, may due to 1.
: phenergan severe chemical irritation or even gangrene
: 2. compartment syndrome
: 3. directly N, damage
: Also, I may keep in mind if it would be coincidence of systemic problems,
: like MS?
: As a PMD, while awaiting for neuro consult, I would order MRI of lumar spine
: and pelvic and right LE. Further EMG and nerve conduction study may be done
: by neurologist.
: What did you say?
|
C****o
发帖数: 994 | 7 Any radio/physical evidence that can differentiate these possible Dx?
spine
done
【在 N*G 的大作中提到】
: I would suspect the local nerve injury (sciatica N.?) first, may due to 1.
: phenergan severe chemical irritation or even gangrene
: 2. compartment syndrome
: 3. directly N, damage
: Also, I may keep in mind if it would be coincidence of systemic problems,
: like MS?
: As a PMD, while awaiting for neuro consult, I would order MRI of lumar spine
: and pelvic and right LE. Further EMG and nerve conduction study may be done
: by neurologist.
: What did you say?
|
A*******s
发帖数: 9638 | 8 How about lawsuit? Any speculations?
I have to go, will be back tonight. |
N*G
发帖数: 217 | 9 Go to lawsuit already? What's exactly happened then? |
N*G
发帖数: 217 | 10 This is why I want MRI. Anyway, I am not neuro specialist. Maybe ACNE can
give us more info..
【在 C****o 的大作中提到】
: Any radio/physical evidence that can differentiate these possible Dx?
:
: spine
: done
|
|
|
A*******s
发帖数: 9638 | 11 Page acne.
Anyone thought about conversion?
【在 N*G 的大作中提到】
: This is why I want MRI. Anyway, I am not neuro specialist. Maybe ACNE can
: give us more info..
|
y***d
发帖数: 33 | 12 Sounds like the pattern described suggestsL5-S1 injury, which is consistent
with sciatic nerve. Would definitely consider nerve injury during IM
injection a possibility, particularly if the patient is thin. Would
prednison help in this case?
As far as conversion disorder goes, does anyone know if the symptom also
follow dermatomal distribution? My guess would be no. But who knows, maybe
the nurse is very good at her anatomy. |
A*******s
发帖数: 9638 | 13 You are right about the dermatomes. And there is no doubt the needle hit a
nerve.
Steroids may be helpful.
But here is my concern:
The sensory exam showed a very limited sensory loss on the foot. But the
motor exam indicated not only foot dorsiflexion but also plantar plexion
weakness. This does not make sense at all. A needle stick on the buttock
caused a complete sciatic motor nerve paralysis with relatively sensory
intact? Even a secondary compartment syndrome won't provide a picture like
that.
This nurse felt being ignored. This possibly explains why it happened. The
shooting pain at the injection was real and it happens. But her symptoms
and signs do not convince me her problems are organic.
Time will tell. And I am waiting for the updates from the author.
consistent
【在 y***d 的大作中提到】
: Sounds like the pattern described suggestsL5-S1 injury, which is consistent
: with sciatic nerve. Would definitely consider nerve injury during IM
: injection a possibility, particularly if the patient is thin. Would
: prednison help in this case?
: As far as conversion disorder goes, does anyone know if the symptom also
: follow dermatomal distribution? My guess would be no. But who knows, maybe
: the nurse is very good at her anatomy.
|
V*****G
发帖数: 337 | 14 One feature about conversion is that patient seems to be unconcerned about
their symptoms. In this case, maybe malingering?
Interesting case, we will see what it turns out to be.
a
【在 A*******s 的大作中提到】
: You are right about the dermatomes. And there is no doubt the needle hit a
: nerve.
: Steroids may be helpful.
: But here is my concern:
: The sensory exam showed a very limited sensory loss on the foot. But the
: motor exam indicated not only foot dorsiflexion but also plantar plexion
: weakness. This does not make sense at all. A needle stick on the buttock
: caused a complete sciatic motor nerve paralysis with relatively sensory
: intact? Even a secondary compartment syndrome won't provide a picture like
: that.
|
A*******s
发帖数: 9638 | 15 I do not think so.(malingering)
But I see more conversion in health care professionals.
【在 V*****G 的大作中提到】
: One feature about conversion is that patient seems to be unconcerned about
: their symptoms. In this case, maybe malingering?
: Interesting case, we will see what it turns out to be.
:
: a
|
V*****G
发帖数: 337 | 16 Ok, good to know this.
Health care professionals can 'fake' unconsciously real good..... LOL...
【在 A*******s 的大作中提到】
: I do not think so.(malingering)
: But I see more conversion in health care professionals.
|
A*******s
发帖数: 9638 | 17 Subconsciousness is the better word to describe conversion.
Conversion is no fake. You have to treat them as real diseases and show
your care. I've found referral to pshchiatry only makes the thing worse.
【在 V*****G 的大作中提到】
: Ok, good to know this.
: Health care professionals can 'fake' unconsciously real good..... LOL...
|
y***d
发帖数: 33 | 18 I have to say I did not thing much about the discrepency between the sensory
and motor findings. Interesting...Within the nerve, how are the fibers
arranged? Sensory wrapping motor? Motor wrapping sensory? Sensory running
next to motor? I have no idea. I imagine a needle injury can be quite
focused.
consistent
【在 y***d 的大作中提到】
: Sounds like the pattern described suggestsL5-S1 injury, which is consistent
: with sciatic nerve. Would definitely consider nerve injury during IM
: injection a possibility, particularly if the patient is thin. Would
: prednison help in this case?
: As far as conversion disorder goes, does anyone know if the symptom also
: follow dermatomal distribution? My guess would be no. But who knows, maybe
: the nurse is very good at her anatomy.
|
