a 48-year-old woman with breathlessness and difficulty walking

on monday we saw a very pleasant middle-aged woman, a pretty heavy smoker, with a history of COPD

she had had multiple courses of oral steroids in the past but no previous admissions until last week when she had a short stay for an infective episode

she become breathless enough to significantly restrict her activity around 24 hours post discharge

we focused on examining her so did not talk much about her symptoms

we could have explored possible reasons why she deteriorated

what do you think?

possibilities that spring to my mind are:

- ineffective treatment for respiratory infection (eg resistant organism)
- PE
- pneumothorax
- heart failure
- something else
_ _ _

thanks to our patient's forbearance, we examined her chest & legs (neuro) in detail

thoughts:

- make an effort to really stand at the end of the bed and LOOK:
you can determine asymmetry, depth of breathing, colour, adjuncts and much more; in this case we would have been able to get the diagnosis from just looking without doing anything else

- practise percussing things: in the experience the key is having a very stiff middle finger of the left hand, and a very floppy right wrist; you can percuss lots of things (eg walls to see where joists are, barrels to see how full they are)

- most medical students find neurological examination hard - so you are not alone!

- knowing some neuroanatomy helps, as does giving clear instructions

- i have mentioned my favourite neuro learning resources before

our patient had weakness of left ankle dorsiflexion and a lost left ankle jerk, suggesting an S1 root lesion; her sensory loss was patchy

her leg symptoms are long-standing; we did not look at previous spinal imaging -we should have done!
_ _ _

Salaam

s