Any ideas on this one?

Epi-do

Epi-do

I see dead people
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Had a patient that said they had gotten up out of bed in the morning, went into the bathroom, and while using the toilet had a "temoring" or "shocking" sensation and fell to the floor. They had a similar episode occur 3-4 months prior to this episode and went to the ER at that time. At that time, labs were drawn and a head CT was done. Everything came back completely normal.

The only diagnosed history the patient has is hypertension. They take HCTZ and Cozaar to control it, but had not yet taken their meds on this day since they were just waking up. BP was 160s/100s. Pulse, RR, BGL were all within normal limits. Skin was WPD, BBS were =/clear. Pt was A&Ox3. They were sinus on the monitor, and a 12 lead was unremarkable. Cincinatti Prehospital Stroke scale was unremarkable.

The patient stated they felt dizzy (as if they were spinning), and was slightly unsteady on their feet when taking the 3-4 steps to the cot. They were bioxing 97-99% on room air. 4 lpm O2 via NC did not have any affect upon how the patient was feeling. Family stated the patient appeared to be acting normally.

I realize this could have been some sort of transient episode that I may never find out the cause of, but was wondering if anyone had any ideas what may have caused it. I had though possibly a TIA or maybe the patient vagalled down. Other thoughts I had were some sort of focal seizure, or something cardiac that I just couldn't catch with the monitor or wasn't necesarily electrical in nature.

I am going to try and follow up with the ER next shift if we get back over there just to see if they found anything. In the meantime, does anyone have any ideas they would like to share with me. It just has me stumped since everything I am able to look at seems to be within normal limits.
 
Undiagnosed MS (multiple sclerosis)
 
It would only be a guessing game without more definitive diagnositcs. A CT Scan will not show everything and may actually show very little depending on the type of scanner and if the test was done with contrast or not. MRI, caroid studies and various other angiograms may also be in her future. There are also many more lab tests that will be done before a direction toward one or more medical diagnoses can be made.
 
VentMedic said:
It would only be a guessing game without more definitive diagnositcs. A CT Scan will not show everything and may actually show very little depending on the type of scanner and if the test was done with contrast or not. MRI, caroid studies and various other angiograms may also be in her future. There are also many more lab tests that will be done before a direction toward one or more medical diagnoses can be made.
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I personally would like to see what a nerve conduction study would show, since that's what it sounds like; some sort of firing of impulses that went hay-wire.
 
I'm going to go with witchcraft. Burn her clothes, and bathe her in salt water laden with the Holy Sacrament.

Kidding aside, I agree with VentMedic that it's impossible for us to know without a battery of in-hospital testing. But if we just want to provide a guess, I would wonder about some sort of undiagnosed seizure disorder. Sudden muscle pain, dizziness, tremoring... My cousin had epilepsy, and some of her more mild seizures she could feel coming. She would sit down wherever she was, and just wait for it. She would later describe it as feeling like she was being electrocuted and couldn't stop shaking. Of course, later on she would feel normal.

Though this doesn't sound like your typical seizure, lacking usual tonic-clonic activity, it could be something related.
 
Out of curiousity, how old and what sex is the patient? Have they done an MRI with contrast yet?
 
Kaisu said:
what about a vagal response to bearing down... happens a lot...
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I can see that if he/she presented with syncope, but the pt. said they felt tremors and a shocking sensation. I've never seen someone get tremors off of near syncope.
 
VentMedic said:
It would only be a guessing game without more definitive diagnositcs. A CT Scan will not show everything and may actually show very little depending on the type of scanner and if the test was done with contrast or not. MRI, caroid studies and various other angiograms may also be in her future. There are also many more lab tests that will be done before a direction toward one or more medical diagnoses can be made.
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I realize alot of diagnostic testing would have to be done for a definative diagnosis. I just have never had a patient complain of a "shocking" feeling before, and was curious if anyone else had any sort of experience/ideas with the complaint.

Juxel said:
Out of curiousity, how old and what sex is the patient? Have they done an MRI with contrast yet?
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Female, early 70's. I don't know if she had an MRI with the previous episode. All that was mentioned was a CT. Since we caught this run at the very end of our shift, I wasn't able to get back to the ER to find out anything else yet.

Kaisu said:
what about a vagal response to bearing down... happens a lot...
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That is one of the things I had thought of, but thought the "shocking" description was an odd complaint to associate with a vagal response.
 
I agree with the assessments of a possible nerve impingment or possible TIA. The other thing you have to consider is a tumor of either the spinal cord or the brain. In any case, since the CT was reported as "normal" I think that the nice step is most definately a MRI with contrast ALONG with a MRA to map the vascular system.

I did have one patient that was similar to this quite a few years ago - it wound up being an acustic neuroma. The patient had syncope similar to what you described, no hearing loss, however the "shocking sensation" was not part of the presenting symptoms.

Interesting in any case, please post the follow up!
 
Shocking

Maybe they need to check the electrical wiring in the house?

"In the toilet" points to vagal for my money - if they are straining they may also constrict a limb nerve or two by tensing up muscles - it's a thought anyway. Hard to say. Pts often have odd ways of describing how they felt.

MM
 
I know it's a longshot, but I have heard of people putting pressure on nerves from sitting on a toilet seat in just the right way. It makes he extremity on that side twitch and kinda feels like a shock. Maybe between that and the Vagalling she had her episode. I doubt thats what it is. But it's a guess.
 
post micturation convulsion syndrome could be a simple explanation for her symptoms.
 
Thanks for all of the input guys! I wish I had an update for you, but I have yet to make it back to that particular hospital. If I am able to find anything out, I will be sure to let everyone know what it turned out to be.
 
Tremoring and shocking of what?

Sure sounds neuro, but was it lower limb(s), back, head, arm, one limb, or ??
You can strain for a BM and compress a vertebral foramen or shift a bad disc at say T1-2-3..lead to shocking sensation down the leg(s), down the back, and tremoring afterwards. Or making something vascular bulge in her head. Lots of things, but it sounds neuro.
 
my only thought was TIA. The shocking is quite interesting as well. Did she have any headache?
 
The only problem with micturation or a vagal response is the first episode happened in the middle of Walmart, and not while the patient was in the bathroom.

mycroft, she said the shocking sensation was all over, and not just one extremity or region of the body.

8jimi8, no, she did not complain of a headache.

Still haven't gotten back to that particular hospital, so no update from the ER.
 
Still haven't gotten back to that particular hospital, so no update from the ER.
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Well take them to a more common hospital next time >:[ :P
 
Your original case purported she had had a similar episode in the past with no diagnosis.

Perhaps she was treating Wal-mart like Larry the cable guy and feels those toilets should be labled for display only.....:P
 
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