mlawizard

Instructions

You are a foundation year doctor in A&E. A patient with known prostate cancer presents with severe back pain and progressive weakness in both legs.

1. Take a focused history from the patient.

2. Explain your differential diagnoses and management plan to the examiner.

Checklist

Checklist "NeurologyHistory" not found

Management

Explain most likely differential diagnosis is Malignant Spinal Cord Compression.
Explain less likely and red flag differential diagnoses could be vertebral fracture, spinal abscess, non-malignant cord compression.
Suggest bedside investigations of full neurological examination including power, sensation, reflexes, cranial nerves.
Suggest laboratory investigations of FBC, U&Es, CRP, clotting, PSA.
Suggest imaging of urgent whole spine MRI within 24 hours (or within 1 hour if complete paralysis), CXR.
Suggest interventions of immediate hospital admission, urgent oncology and neurosurgical referral, immediate dexamethasone 16mg, regular analgesia, thromboprophylaxis, bladder and bowel care, physiotherapy assessment.

Internally Approved

Surname/Nom (1)

Mitchell

Given names/Prenoms (2)

Harold

Date of birth/Date de naissance (4)

09 MAR 1953 (71)

Sex/Sexe (5)

PRESENTING COMPLAINT

You've had worsening mid-back pain for the past 2 weeks. Over the last 24 hours, you've noticed weakness in both legs and difficulty walking. You've also been having problems controlling your bladder.

IDEAS, CONCERNS AND EXPECTATIONS

You're very worried because the pain is much worse than your usual back pain and you're scared about not being able to walk. You want to know if this is related to your cancer.

SYSTEMS REVIEW

Severe band-like pain around T8 level. Progressive bilateral leg weakness. Recent onset urinary incontinence. No fever. Some constipation. No numbness in saddle area yet. Pain worse when lying flat.

PAST MEDICAL HISTORY

Metastatic prostate cancer diagnosed 2 years ago with known bone metastases. Hypertension. Type 2 diabetes.

DRUG HISTORY

LHRH analogue injections every 3 months. Bicalutamide 50mg daily. Amlodipine 5mg daily. Metformin 500mg twice daily. Paracetamol and codeine for pain.

FAMILY HISTORY

Father had prostate cancer.

SOCIAL HISTORY

Retired builder. Lives with wife who is main carer. Previously independent but struggling with mobility last few days. Ex-smoker (quit 10 years ago). No alcohol.