A 35-year-old male presented to a large urban ED complaining of 2½ weeks of numbness in the ulnar aspect of both arms. The pain would occasionally shoot down both arms when he coughed or sneezed.
In the prior week, he had developed numbness and tingling on the right side of his abdomen that had gradually migrated down both legs, but was worse on the right. In the prior three days, both legs had started to feel weak and occasionally buckle. He was not on any medication other than ibuprofen and denied any trauma, arm weakness, headache, fever, or vision changes. He mentioned that he had been to his chiropractor a few times over the past five months for treatment of a small area of pain in the posterior thorax, just medial to his left shoulder blade, and had no relief from manipulation.
Triage vital signs were normal. The physician physical exam was documented to show tenderness in a small area just medial to the left scapula. Sensation was intact, and the patient was able to squat and to heel/toe walk unassisted. Plain films of the cervical spine showed mild to moderate degenerative narrowing of C4 through C7 disc spaces. A CT of the head was normal. No labs or other testing was done.
The documented diagnostic impression by the emergency physician (EP) was as follows: Arm, leg and abdomen numbness and bilateral leg weakness, unknown cause. The patient was discharged with no medication. Neurology follow-up was recommended, but the next available appointment was a month away.
Over the following weeks, the patient’s symptoms continued. He also developed sharp pain running down his spine when he tipped his head forward. He continued seeing the chiropractor but was referred to the ED for further evaluation due to lack of improvement. Approximately one month after the first visit (and two days prior to his neurology appointment), he returned to the ED for his worsening symptoms. The history at this second visit documented continued pain around the left shoulder blade that was worse with deep breathing or flexion of the neck and that would “shoot” to his arms when he bent his head forward. Difficulty walking was also noted. The patient did not complain of headache, low back pain or bowel/bladder problems.
Vital signs were again normal. The physical exam was also documented as normal. Neurologic evaluation stated, “The patient is alert and oriented with no focal weakness or deficits.” CT scan of the brain and chest x-ray were normal. Plain films of the thoracic spine demonstrated “multilevel mild degenerative endplate and anterior spondolytic changes with associated disc space narrowing.” No other testing was performed.
The diagnostic impression was “left scapular pain, unknown etiology.” The patient was discharged with prescriptions for Valium and Vicodin and was instructed to follow up in the neurology clinic in two days.
Not knowing the outcome of this case, was the management by the two emergency physicians reasonable practice? Why or why not? Comment below or send your response to firstname.lastname@example.org.