Bedside Diagnostic Challenge – 44-year-old woman with unsteady gait

Paul Griner, MD, MACPBedside Diagnostic Challenge, Internal Medicine, Medical News

Bedside Diagnostic Skills Challenge on neuropathy

Today’s Bedside Diagnostic Challenge question comes from the desk of Med-Challenger Internal Medicine Editor-in-Chief, Paul F. Griner, MD, MACP.

Test your bedside diagnostic skills with this review question.


A 44-year- old woman presents to the emergency department of her local hospital with a complaint of an unsteady gait for the past 4 weeks. The unsteadiness began as a slight stumbling during the day. It became progressively worse to the point that she began bumping into furniture and, on one occasion fell to the floor. She has also noted numbness and tingling in her hands and feet in recent weeks. She did not have a “cold” before the unsteadiness began. She has otherwise felt well. Her past history includes a prolonged period of general weakness about a year ago but no unsteadiness on walking. She was given some advice by a friend to take an over the counter medication (a powder) from the naturopathic section of the pharmacy that she uses. She has taken this on a daily basis over the past year. She states that it “cured” her general weakness. She does not know the name of the powder and does not have it with her.

Physical examination reveals a woman of stated age who does not appear ill. Temperature is 98.8° F, blood pressure is 112/70 mmHg, pulse is 74 and regular and respirations are 16/minute. Examination of the head, eyes, ears, nose, throat, lungs, abdomen and extremities does not reveal any abnormalities. Neurologic examination shows marked instability on walking. She also has a positive Romberg sign. There is decreased sensation to vibration at her ankles and wrists. There is also decreased sensation to pin prick and a cotton ball over the ankles and wrists. Reflexes are hypoactive. Motor strength appears to be normal.

Laboratory studies:
Hemoglobin – 13 gm/dL
Hematocrit – 39%
MCV – 94 um3
White blood cell count – 6,500/mm3
Serum iron and B-12 levels – pending


Based on the diagnostic value of careful listening and looking …

What is the most likely naturopathic drug that this patient is taking?

Answer Options:




Folic Acid

Answer Explanation & References:

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This case was sampled from Med-Challenger IM, the #1 online internal medicine review. Stay up to date with Med-Challenger, the most current clinical knowledge review & MOC efficiency products available.

About Bedside Diagnostic Challenge:

Except for Hospitalists, Emergency Medicine physicians, and Interventional Cardiologists, most internists will spend the bulk of their professional time with patients in an office setting.

Here is where finely tuned clinical skills are most important in leading to accurate diagnoses, fewer complications resulting from unnecessary tests and procedures, and lower costs. Med Challenger Bedside Diagnostic Challenge reinforces the value of these clinical skills and tests users on their knowledge of them.

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About the Author:

Paul Griner MD, MACP graduated from the University of Rochester School of Medicine and completed his residency at the Massachusetts General Hospital, Boston, MA. He returned to Rochester as Chief Resident in Medicine and Hematology Fellow and remained in their Department of Medicine, rising to Professor. He served as a Senior Lecturer at Harvard Medical School and consultant at the Massachusetts General Hospital where he introduced a mentoring program for the faculty of General Internal Medicine.

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