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A 45-year-old patient with insomnia, fatigue, weight gain, amenorrhea, and uniformly enlarged uterus is evaluated for pregnancy with an hCG level despite perimenopausal 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ValuesNotesCalculatorReverse ColorText Zoom\n\nA 60-year-old woman comes to the office due to \"balance problems while walking.\"The patient has had 2 falls over the last 2 months associatedwith tingling in her feet and dull pains in her back and legs.Medical history is notable for type 2 diabetes mellitus;her most recent hemoglobinA1c was 7.6%.Neurological examination reveals decreased muscle strength in both legs,diminished proprioception peripherally in the feet,decreased pain sensation in the feet and ankles,a hyperactive right knee jerk,and an upgoing plantar reflex on the right side.Which of thefollowing is the most appropriate next step in management of this patient's symptoms?○ A.MRI of the spine○ B.Nerve conduction studies○ C.Physical therapy referral  \n○ D.Repetitive stimulation electromyographyO E.Tight blood glucose control  \nSubmit  \nSettings  \nThis patient with diabetes mellitus has back and leg pain associated with weakness,paresthesia in the feet,and right-sided hyperactive knee jerkand upgoing plantar reflex.Although neurologic complications are extremely common in patients with diabetes,patients usually develop distalsymmetric polyneuropathy(ie,diabetic neuropathy)that causes a \"stocking and glove\"pattern of sensory loss,impaired proprioception andvibratory sense,and diminished ankle reflexes.Rarely,motor weakness can occur but is typically a late manifestation(eg,after years)of severedisease and follows a similar distribution.  \nTherefore,several components of this patient's presentation suggest a more serious etiology than simple diabetic neuropathy.The asymmetrichyperactive knee jerk and positive Babinski sign (ie,upgoing plantar reflex)are concerning for an upper motor neuron process (in contrastto diabetic neuropathy,which strictly affects the lower motor neurons).In addition,diabetic neuropathy is unlikely to cause weakness that ispresent throughout the legs and is of relatively rapid onset(eg,months)as compared to the sensory manifestations.  \nTaken together,these findings make the patient's history of back pain more concerning because it may be indicative of a mass lesion in thespine.The patient should be questioned about recent fevers (concerning for epidural abscess)or weight loss(concerning for malignancy).AnMRI of the spine should be performed to evaluate for cord compression.  \n(Choices B and D)Nerve conduction studies and electromyography can be used to confirm a suspected diagnosis of diabetic neuropathy but arenot helpful in diagnosing a condition with the spinal cord,as suggested by this patient's upper motor neuron findings.  \n(Choice C)A physical therapy referral would not be the appropriate next step for this patient because it would likely delay the probable diagnosisof cord compression.  \n(Choice E)This patient's hemoglobin A1c is high and in the long term she would likely benefit from tighter blood glucose control.However,themore concerning,immediate issue is the cause of her upper motor neuron findings because delay in diagnosis would likely lead to worseningneurologic deficits.  \n## Educational objective:\n\nDiabetic neuropathy is a distal,symmetric polyneuropathy that can cause a \"stocking and glove\"pattern of sensory loss,impaired proprioceptionand vibratory sense,and diminished ankle reflexes;motor findings may be a late manifestation in severe disease.Hyperactive reflexes and anupgoing plantar reflex are inconsistent with diabetic neuropathy and are suggestive of an upper motor neuron process.  \n## Clinical Neurology/Medicine\n\nNervous System  \nSpinal cord compression  \nSubject  \nSystem  \nTopic  \nCopyright ◎LIWorld.All richts reserved  \nA45-year-old woman comes to the office due to increasing difficulty sleeping for the past few months.She is unable to concentrate at work and isnot exercising due to fatigue.The patient reports a 4.5-kg(9.9-Ib)weight gain and is now unable to wear her normally fitting cl","cbCaiv8SaknzJ7KE","https://ap.wps.com/l/cbCaiv8SaknzJ7KE","pdf",40987881,140,"English","## Upper motor neuron findings in diabetic patients\n## Next step: MRI of the spine\n## Perimenopause vs pregnancy evaluation with hCG","[{\"question\":\"How should the second patient’s amenorrhea and enlarged uterus be evaluated?\",\"answer\":\"All reproductive-age patients with amenorrhea and signs of pregnancy should be evaluated with an hCG level, even when symptoms overlap with perimenopause.\"}]","Diabetic Neuropathy vs Spinal Cord Compression - Educational Objective | PDF",1791593216,353]