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Case 38
A 73 year-old man is referred for pain, numbness, and weakness in his legs for several years. It began
as aching and numbness during his daily walks, worse on the right, and most prominent in the calves
and posterior thighs. Some days he could walk a mile or more with little difficulty, but some days he
would have to sit and rest after a few blocks. For the past year, when he has symptoms, he notices his
legs feel “rubbery,” as if they might give out from under him. He is a retired nurse, and says that he’s
had back pain for as long as he can remember. Other than an ACE inhibitor for hypertension and an
ibuprofen for his back and leg pain, he takes no medications. Other than these symptoms, he has been
feeling entirely well.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you treat this patient? How would you
counsel the patient about his condition and about any proposed therapy?
Case 38
A 73 year-old man is referred for pain, numbness, and weakness in his legs for several years. It began
as aching and numbness during his daily walks, worse on the right, and most prominent in the calves
and posterior thighs. Some days he could walk a mile or more with little difficulty, but some days he
would have to sit and rest after a few blocks. For the past year, when he has symptoms, he notices his
legs feel “rubbery,” as if they might give out from under him. He is a retired nurse, and says that he’s
had back pain for as long as he can remember. Other than an ACE inhibitor for hypertension and an
ibuprofen for his back and leg pain, he takes no medications. Other than these symptoms, he has been
feeling entirely well.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you treat this patient? How would you
counsel the patient about his condition and about any proposed therapy?