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The Case of the Paterson Shake

The Case of the Paterson Shake. Anthony Furiato , DO, PGY-III St. Joseph’s regional medical center Paterson, NJ ACOEP Scientific Assembly, CPC, 2014. Chief Complaint. Shortness of breath with shaking. Pre-Hospital Care. Paramedics on scene Peripheral IV established

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The Case of the Paterson Shake

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  1. The Case of the Paterson Shake Anthony Furiato, DO, PGY-III St. Joseph’s regional medical center Paterson, NJ ACOEP Scientific Assembly, CPC, 2014

  2. Chief Complaint Shortness of breath with shaking

  3. Pre-Hospital Care • Paramedics on scene • Peripheral IV established • Supplemental O2 by NC initiated • Cardiac monitor placed

  4. HPI • 81 year old male • 2-3 months of increasing, intermittent, shortness of breath • Extremely weak this AM, unable to walk • SOB worse with shaking episodes • Onset of shaking over the past year, intermittent, no history

  5. HPI cont. • Wife states pt is alert and awake during shaking episodes • Shaking has become more frequent, seems to be on the right side • Has never sought PMD evaluation for shaking • Pt also admits to increasing low back pain for the past 2-3 days, no trauma

  6. Historical • Past Medical History: HTN, Hyperlipidemia, CAD, PVD, Dementia, BPH • Past Surgical History: Cardiac Stent • Medications: Hydralazine, Metaxalone, Xarelto, Pravastatin, Ranexa, Amlodipine, KCl, Donepezil, Tamsulosin, Namenda, Metoprolol, Lasix • Allergies: NKDA • Family History: Non-contributory • Social History: No tobacco, alcohol, or illicit drug use

  7. Review of Systems • Constitutional: Negative for fever, fatigue, chills, weight loss • Cardiovascular: Negative for chest pain, edema, orthopnea, palpitations • Respiratory: Positive DOE, SOB. Negative for cough, sputum, hemoptysis • Abdomen/GI: Negative for abd pain, nausea, vomiting, diarrhea, constipation, abdominal cramps/distention • GU: Negative for difficulty urinating, incontinence. • Back: Positive pain at rest and with movement (lumbar) • Neurologic: Positive for abnormal shaking movements. Negative for dizziness, headache, syncope/near-syncope, numbness, tingling, paresthesia, weakness • All other systems reviewed and are negative

  8. Vital Signs • BP: 125/102 • Pulse: 103 • Respiratory Rate: 20 • Pulse Ox: 99% on RA • Temperature: 97.6F

  9. Physical Exam • General: Patient appears no acute distress, alert, awake, comfortable. Appears stated age. • HEENT: Normocephalic, atraumatic. Pupils 4mm bilaterally. PEERL, EOMI, no conjunctival pallor or scleral icterus. Nares patent, no discharge. Tympanic membranes are within normal limits. Airway patent. Dentures in place. • Chest: No signs of trauma, symmetrical chest rise and fall with inspiratory effort, non-tender, no crepitus

  10. Physical Exam • Cardiovascular:Regular rate and rhythm, normal S1 and S2, no murmurs/rubs/gallops • Respiratory: No signs of respiratory distress. Normal, symmetrical respirations with no use of accessory muscles or tachypnea. Breath sounds are clear throughout, no wheezing/rhonci/rales/decreased breath sounds. • Abdomen/GI: Soft/nontender in all quadrants. No masses palpated. No guarding/rebound/tenderness. Bowel sounds active in all four quadrants

  11. Physical Exam • Back: Mild tenderness with palpation of the right lumbar paraspinal musculature. Obvious muscle spasm. No vertebral or CVA tenderness. Full ROM without pain. • Neurologic: AAOx4. Lucid, follows command. CN II-XII intact. Motor strength +5/5 in all extremities. No sensory deficits. Normal muscle tone. Finger-nose testing and heel-shin testing normal. Reflexes +2/4 bilaterally (patellar, Achilles). Walks without assistance or difficulty. • Extremities: No cyanosis, edema, no pulse deficits, no tenderness to palpation to all 4 extremities • Skin: Warm, dry, intact. Good turgor.

  12. Patient consent obtained for following physical exam finding

  13. Physical Exam

  14. ED Course • Continuous cardiac monitor with pulse oximetry placed • EKG • Lab work sent • IV saline lock • Neurology consult

  15. EKG

  16. CXR

  17. Laboratory Results 14.6 137 106 19 Troponin-I: 0.006 CPK: 83 BNP: 70 D-Dimer: 0.30 PT/INR: 28.4/2.7 PTT: 37.3 Ca: 9.4 Mg: 2.2 Phos: 3.5 117 5.5 140 4.8 24 1.59 43.8 T-Bili: 1.0 T-Protein: 7.1 Albumin: 4.3 AlkPhos: 63 AST: 14 ALT: 12 S:65% L:19% M:13% E: 2% B:1%

  18. CT head w/o contrast

  19. ED Course • RN notes that patient desaturates to 90% on RA during shaking episodes • Neurology Consult • Recommended stat EEG • Agreed with plan to order MRI of thoracic and lumbar spine • EEG: No seizure activity noted during jerking movements. Normal awake study

  20. MRI Cervical Spine

  21. MRI Thoracic Spine

  22. ED Course • Patient’s primary care doctor and consultants are made aware of current findings and agree with admission to neurology floor. Care assumed by PMD. • Orthopedic consult called • Repeated episodes of jerking movements noted in the ED, lasting for less than 5 minutes • What is the diagnosis?

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