Part 1.
Brian, 27-year-old-male graduate student, presents himself to the University Health Service for an examination following an injury that occurred in a rugby game approximately three days ago. A fourth-year medical student examines him.
Patient History:
The medical student obtains the following medical history from Brian:
• 27-years old, 6'0" and weighs 190 lbs.
• Unremarkable medical history.
• Patient participates in regular physical activity, running and wegight lifting six days a week on an alternating schedule (run Monday, Wednesday, Friday, lift Tuesday, Thursday and Saturday).
• Patient is a "recreational" rugby player, playing for an intramural university team. He played football and wrestled during high school and college, earning All-American status in both sports during his junior and senior years in college.
• Brian obtained a minor back injury during a scrum in a rugby game approximately ten days ago, and the injury and associated back pain has continued to aggravate the patient.
Physical Examination reveals the following information:
• Deep bruising in the lower back. The bruise is clearly dissipating.
• Low back pain located approximately in the same region as the bruise that appeared within 24 hours of receiving the blow to the back during the rugby scrum.
• Pain upon palpation and percussion in the region of the bruise is clearly evident.
An X-ray of the affected area is normal, with no fracture of the lumbar region of the vertebral column or pelvis.
The patient is given a muscle relaxant, told to ice the area and advised to refrain from strenuous physical activity for the next ten days.
Part 2.
Two weeks after the initial examination Brian again presents to the University Health Service. Brian has noted that symptoms have persisted and changed since his last visit to the Health Service. Brian has noted that he has not been able to obtain an erection the preceding evening, but he attributed that to nervousness from his upcoming thesis defense. However, just recently Brian has encountered difficulty controlling his bladder and bowels within the last 24-36 hours, prompting his second visit to the Health Service. He feels like he has to urinate but not much comes out. He was on the toilet and was not aware he was passing stool until it was already coming out. The same 4th year medical student examines Brian the second time and asks for a consult with the senior resident.
Physical exam, history and tests yield the following:
• The back pain has persisted, and is now radiating bilaterally into both legs.
• Extension at the metatarsophalangeal joints is 2/5
• Abduction of the metatarsophalangeal joint of the great toe is 2/5
• Flexion of the metatarsophalangeal joint of the great toe is 2/5
• Babinski sign is absent in both lower limbs.
• His reflexes are hypoactive at the right knee, and absent at the left knee and both calcaneal tendons.
• Sensation to sharp and dull is diminished below the knees on the anterior and posterior surfaces of his lower limbs all of the way up to, and including the buttocks. X-ray of the pelvis and lower back are normal again.
• Brian notes that toilet paper feels different to the touch upon wiping following a bowel movement.
• Erectile dysfunction
• Catheterization for determination of residual urinary volume is positive
Questions
- What is your diagnosis for this patient? Provide a detailed analysis of the signs and symptoms along with reference to scientific literature.
- The patient's symptoms appear to be neurological. Locate the level of the lesion, and give a solid anatomical reason for your response. Explain how you came to this conclusion.
- Explain why the somatic and autonomic branches of the patient's nervous system are involved.
- What specific muscles and nerves were tested by the resident's examination of Brian?
- What specific mechanism causes the neurological dysfunction? Give a detailed anatomical description of the structures involved.
For every question provide an in depth and detailed explanation, citing resources found in the Health Sciences Databases and addressing the three perspectives. At least three sources should be cited. Students are expected to follow course policies and the student code of conduct.
Sample Solution