Clinical Case 044: Neuro Curio
A 40 yo. woman presents for review to her GP a week after having a laparoscopic cholecystectomy.
She had been suffering with epigastric pain and and US showed gallstones, and a contracted GB. So she elected to undergo cholecystectomy.She was discharged the morning after the surgery with oral oxycodone and paracetamol for pain.
PMHx: anaemia, mild depression. She takes an iron supplement and citalopram 20 mg daily
Today she has recovered well from the procedure, but has developed bilateral tingling of the hands since leaving hospital and it has not improved – in fact she now says after a week it has spread up her arms, and her toes feel ‘tingly’ over the last few days.
OK – that is it. Usually when I put up these cases you smart docs work it out in a heartbeat – so I am giving you the minimum amount of info! 80% of diagnosis is on history – so go for it…
What is the diagnosis? What investigation will make you look like a super-Sherlock? and what intervention will fix her?
There just might be a real prize if you are first in! Casey
Oxycodone -> *ahem* ‘bowel sluggishness’ -> hypocalcaemia?
Or if it’s a bit more serious – peri operative parathyroid infarction due to intraoperative hypotension?
Best guess (and it’s a guess) is that the abdo pain wasn’t gall bladder but porphyria. GA can then trigger further crises (esp of thio used or bp low etc) and the glove and stocking progressive neuropathy could be typical.
Laparoscopic surgery involving gut handling has been associated with dyselectrolytaemias including hypocalcaemia. CO2 insufflation of peritoneal cavity may also be implicated in Ca shift leading to extremity parasthesia?
needs b12 replacement
check out this
Pancreatitis spring to mind too, but to cause hypocalc I’d expect her to be more unwell and have abdo pain!
Reckon Minh has just proved he is smarter than the rest of us!