A 28-year-old woman has been experiencing intermittent unilateral “heaviness” in her arm and/or leg over the past year. The symptoms recur every few months and usually linger for a few days. The patient also occasionally has pins-and-needles sensations in her fingers and feet. Labs were normal, as was an MRI taken two months after the symptoms started. She has not seen a neurologist in five months, but her symptoms recently returned and have persisted. Is a lumbar puncture or second MRI warranted?
—Kathleen Birck, FNP, Ridgeland, Miss.

Has the patient had any injury to her neck or back? Request an MRI of both the neck and the lumbar spine to rule out any spinal pathology, especially since this is affecting the upper and lower extremities. I also recommend an electromyelogram/nerve conduction study. This will give you an idea of spinal-nerve impingement, peripheral-nerve compression, or neuropathy. Obviously, a thorough musculoskeletal and neurovascular exam should be performed. Another possibility, if you are unable to find the cause in the spine or the limbs, is a brain lesion. I would certainly consider sending the patient back to her neurologist or, at the very least, requesting a telephone consultation for additional input.
—Michael E. Zychowicz, DNP, NP-C, FAANP (108-19)

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