pain in the lowers limbs

[Aneed333]

Hello
Today , a patient has come to me .He complains about pain in his lower limbs generally , he sometimes falls down during walking and the pain increases during climbs stairs , remarkable , the pain is symmetrical and he already visited a neurologist and the latter told him that there is nothing wrong since his lasted CT shows nothing wrong ... so what could it be his diagnosis ?and Physical therapy is essential for him ?
P..S he told me that his sexual energy has become weak

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[gcoe]

Hi Aneed=333

You really haven't provided much information.

What was the history to the symptoms? slow onset -s if so =over what period of time? fast onset, an incident?

What type of pain?(how does he describe his pain) is it constant/variable?

Does it follow a segmental distribution or not?

Does the patient seem distressed?

[Aneed333]

Hi Aneed=333

You really haven't provided much information.

What was the history to the symptoms? slow onset -s if so =over what period of time? fast onset, an incident?

What type of pain?(how does he describe his pain) is it constant/variable?

Does it follow a segmental distribution or not?

Does the patient seem distressed?

Hi gcoe ,
the the onset is gradual since 4 weeks and not due to incident.
the pain like cramping and variable and it follows segmental distribution

thanks in advance

[gcoe]

Hi Aneed333

Well it is good if the neurologist has cleared him of neurological disease - as long as nothing has been missed.

It is however concerning if there is a segmental distribution as that may indicated something organic. It would be more reassuring if he had nerve conduction testing and an MRI to be sure. I would be concerned about serious spinal cord disease

did you find anything on examination:

• weakness
• changes in deep tendon reflexes
• changes in tone
• abnormal reflexes like babinski or clonus?
• sensory changes
• bladder and bowel

What about his gait is there a consistent disordered pattern?


Given that the patient is falling down when he walks that should be taken very seriously. I think I would advocate for a detailed neurological workup, not just a CT. These are after all severe symptoms suggestive of cord signs including potential

However if it isn't organic he may have some form of somatoform disorder. The fact that he raised the issue about the loss of sexual function could be read at face value and cord be a sign of serous cord pathology. However it could also indicate rather odd behaviour - depending on the context that the topic arose. did you feel comfortable when he said this? - sometimes that can be a clue.

Are you familiar with somataform disorders? These are psychiatric disorders where the patient presents with physical symptoms that can not be explained by organic causes. One type is somatisation disorder which your patient could have:

Somatization disorder: Somatization disorder is characterized by many somatic symptoms that cannot be explained adequately based on physical and laboratory examinations. Specific characteristics of somatization disorder include the following:

* Onset of unexplained medical symptoms in persons younger than 30 years
* Multiple and chronic complaints of unexplained physical symptoms
* Multiple pain symptoms involving multiple sites, such as the head, neck, back, stomach, and limbs
* At least 2 or more unexplained gastrointestinal symptoms, such as nausea and indigestion
* At least 1 sexual complaint and/or menstrual complaint
* At least 1 pseudoneurological symptom, such as blindness or inability to walk, speak, or move

Somatoform Disorders: eMedicine Psychiatry

If the patient does have this it is important to take the patient seriously and not dismiss the symptoms as not real or "in their head". these patient can be helped by supportive physiotherapy but you do need to work along side a psychiatrist or a clinical psychologist on the case. You should never try to treat them on your own. Quite often patients may have a depressive problem or post traumatic stress or some other kind of psychiatric condition. But instead of displaying these anxiety or mood symptoms they "physicalise" their symptoms. sometimes the patient is distressed. or can be very demanding. Sometimes they may be very blasé about their symptoms

Personally I think the patient has a right to be really thoroughly checked out and I don't think a CT is a complete examination

[Aneed333]

weakness
changes in deep tendon reflexes
changes in tone
abnormal reflexes like babinski or clonus?
sensory changes
bladder and bowel

he does not have anyone of the aforementioned symptoms .Actually , I'm not fimiliar to somatoform disorder
Thank you for your response
I appreciate it

[gcoe]

Cheers Aneed333

I forgot to add - with somatoform disorders - the patients are genuinely convinced they have a somatic disease - trying to persuade them otherwise is usually doomed to fail.

[Aneed333]

Thank you again and again
you're an asset source