Differential Diagnosis for Postoperative Difficulty Walking
The patient's presentation of difficulty walking, weakened dorsiflexion of the right foot, and diminished pinpoint sensation of the right big toe after a laparoscopic-assisted vaginal hysterectomy with midurethral sling placement requires a thorough differential diagnosis. The following categories organize potential causes:
- Single Most Likely Diagnosis
- Peroneal nerve injury: This is likely due to the patient's position during the long surgery, which may have put pressure on the peroneal nerve, causing injury. The symptoms of weakened dorsiflexion and diminished sensation in the right foot are consistent with this diagnosis.
- Other Likely Diagnoses
- Postoperative neuropathy: Direct pressure or stretching of nerves during surgery can cause neuropathy, leading to symptoms like those presented by the patient.
- Deep vein thrombosis (DVT): Although less likely given the lack of typical DVT symptoms (e.g., swelling, redness), the patient's recent surgery and immobility increase her risk. DVT could cause pain or discomfort that might contribute to difficulty walking.
- Hematoma or bleeding: The drop in hemoglobin from 12.1 g/dL to 9.9 g/dL suggests some degree of bleeding. A hematoma could potentially compress nerves, leading to neurological symptoms.
- Do Not Miss Diagnoses
- Spinal epidural hematoma: Although rare, this condition is a medical emergency that could present with neurological deficits, including weakness and sensory changes. It requires immediate intervention to prevent permanent damage.
- Pulmonary embolism: While the patient does not exhibit typical symptoms of pulmonary embolism (e.g., shortness of breath, chest pain), it is a potentially life-threatening condition that must be considered, especially in a postoperative patient with risk factors for venous thromboembolism.
- Rare Diagnoses
- Rhabdomyolysis: Prolonged pressure on muscles during surgery could lead to rhabdomyolysis, which might cause muscle weakness. However, this would typically be accompanied by other symptoms such as myalgias and elevated creatine kinase levels.
- Infection or abscess: Early postoperative infection could potentially cause neurological symptoms if it involves or compresses nerves, but this would likely be accompanied by other signs of infection such as fever, redness, or swelling.