A 67-year-old woman comes to the urgent care because she fell in the shower three days ago. She insists that she doesn’t have any symptoms and she says that she slipped on soap. She has not had any headaches or changes in vision, sensory, or motor function before or after she fell.
She had not been planning on coming in for a medical evaluation, but when her son stopped by to visit her at her home, he noticed a bruise on her forehead. When she told him about her falling episode that occurred in the shower, her son wanted her to be evaluated and brought her to urgent care.
She has had osteoarthritis for about 20 years. She lives by herself. She used to work as a cashier and retired three years ago. She drives, and she goes out to do errands about two times a week; other than that, she rarely gets out. She is not physically active. She used to go to church but stopped around the time she retired. She used to smoke one pack of cigarettes per day, and she quit about 10 years ago. She used to drink a few times per year at weddings and no longer drinks at all.
She is awake and alert and oriented x 3. She has a large bruise on the left side of her forehead and what appears to be a clean, healing, superficial wound on her head without any deep cuts. Her skin appears normal. Her blood pressure is 140/75 and her heart rate and rhythm are regular, without any murmurs. She has no carotid bruits. Breath sounds are clear and breathing rate is normal. She has a soft abdomen with normal bowel sounds, no lesions or tenderness. Her pulses are diminished in her lower extremities and normal in her upper extremities.
She has mildly slurred speech. Her language and comprehension are normal. She does not demonstrate any facial asymmetry. Her extra ocular movements are intact with no nystagmus. Her pupils are equal, round and reactive to light. There are no signs of bleeding or trauma to her eyes. Her fundoscopic examination is normal and her hearing examination is normal with no signs of trauma to her ears. She has decreased sensation to light touch, pinprick, temperature and vibration of the left foot and leg. She has normal sensation of bilateral upper extremities. She has brisk reflexes of the right lower extremity and decreased reflexes of the left lower extremity and both upper extremities.
Her strength is 4/5 in the right lower extremity and mildly decreased in her left lower extremity. She has normal strength in bilateral upper extremities. Her coordination is slow but accurate. Her gait is normal when walking. Romberg is positive (she is unable to stand straight with both feet together) and she is off balance when asked to walk heel-to-toe.
A brain CT scan showed a 5 cm subdural hematoma of the left frontal lobe. Her blood glucose level was 210 and her glycosylated hemoglobin was 6.5. She had nerve conduction velocity (NCV) and needle electromyography (EMG) studies, which showed decreased amplitude in all 4 limbs as well as slowed velocity in the left lower extremity.
What's your diagnosis?
1. Maltese G, Tan SV, Bruno E, et al. Peripheral neuropathy in diabetes: it's not always what it looks like. Diabet Med. 2018; 35(10):1457-1459.
2. Petropoulos IN, Ponirakis G, Khan A, et al. Diagnosing Diabetic Neuropathy: Something Old, Something New. Diabetes Metab J. 2018;42:255-269.