Weakness

Medical History

[accordion][accordion_item title=”History of Present Illness”]Patient is a [#] year old [fe]male who presents with [generalized][unilateral][bilateral] weakness in the [proximal][distal] [right][left] [upper][lower] with a [sudden][insidious][episodic] onset [TIME] prior to presentation. +/- changes in [speech] [vision]. +/- [facial droop] [inability to urinate]. Associated [vomiting] [diarrhea] [rash]. Exposure to [ticks] [heavy metal] [recent viral illness] [recent changes in medication].[/accordion_item][accordion_item title=”Physical Exam”]Blood pressure was [ ], pulse was [ ], respirations were [ ], temperature was [ ] pulse ox was [ ]% on [room air]

General: [appear comfortable on stretcher.];
HEENT: [No conjunctival pallor. No oral thrush. No goiter.];
Cardiovascular: [Regular rate and rhythm];
Respiratory: [eu]pneic. Bilateral breath sounds. No wheezes or crackles. Good respiratory effort.;
Gastrointestinal: [Soft, nontender, nondistended in all quadrants.];
Musculoskeletal: [There was no gross deformity];
Skin: Physiologic coloration. No rash consistent with a tick bite.;
Neurologic: Alert and oriented to person, place and time. Follows commands appropriately. Pupils are equal and bilaterally symmetric, and constricts bilaterally appropriately to light in either eye. No ptosis or diplopia on visual field testing. Extraocular motion is intact and does not fatigue on extended testing. Visual acuity is grossly intact in all visual fields. Sensation is intact and symmetrical in the trigeminal nerve distribution. Facial motor movements are symmetric and without signs of weakness. Hearing is grossly intact bilaterally. Able to swallow and shrug shoulder without difficulty. No tongue deviation. No nuchal rigidity. Strength testing of the upper extremities [is 5/5 and equal bilaterally]. Strength testing of the lower extremity [is 5/5 and equal bilaterally]. Patellar reflexes are normoreflexic bilaterally. Muscle tone is not spastic or flaccid. No fasciculations. No signs of atrophy. Sensation is intact in the fingers and toes to light touch. Gait is normal. Hoffman’s sign is negative. No clonus at the ankles bilaterally. Finger-to-nose testing is smooth without dysmetria.;[/accordion_item][/accordion]

Medical Decision Making

[accordion][accordion_item title=”Initial Evaluation and Differential”]

I have considered life-threatening causes of the patient’s presenting symptoms, which included an acute illness, cerebral vascular accident or brainstem infarction, myelopathy, cauda equina, Guilian-Barre Syndrome, botulism, and myasthenia.
I have been able to exclude [these diagnosis] from consideration as it is inconsistent with my history and physical exam.
Differential Exclusions
  • Patient’s symptoms is not consistent with a cerebral vascular accident, lacking any new focal weaknesses or acute changes in mentation on my physical examination.
  • Patient’s symptoms is not consistent with Guillian-Barre Syndrome, as DTRs are almost always absent in the involved extremities, so the presence of normal reflexes on my physical examination makes this diagnosis very unlikely.
  • Patient’s symptoms is not consistent with myasthenia, as a normal extended visual gaze testing and the lack of diplopia or ptosis on my physical examination makes this diagnosis very unlikely.
  • Patient’s symptoms is not consistent with a myopathy or myelitis, as they have a normal gait, no bladder or bowel symptoms, no saddle anesthesia, and no abnormalities of their tone or their reflexes on my physical exam. These findings in combination makes this diagnosis very unlikely.

[/accordion_item][accordion_item title=”Diagnostics”]

Due to my inability to exclude the diagnosis of a [X] from my differential diagnosis with my history and physical exam alone. I decided to obtain [Y] which [Z].
CT-Head
  • Due to my inability to exclude the diagnosis of a cerebral vascular accident from my differential, I decided to obtain a CT-Head, which was negative for any intracerebral infarction or hemorrhage.
Basic labs
  • Due to my inability to exclude the possibility of an acute illness as a contributing factor to the patient’s clinical presentation, I obtained a complete blood count, electrolyte panel, and renal function test studies, which demonstrated no leukocytosis, no gross electrolyte abnormalities, and no significant changes from baseline renal function.
MRI
  • Due to my inability to exclude the diagnosis of myopathy, myelitis, or cauda equina from my differential, I decided to obtain an MRI of the spine, which was negative for gross abnormalities.
ESR and CRP
  • Due to my inability to exclude the diagnosis of myositis from my differential, I decided to obtain ESR and CRP, which was within normal limits, and virtually ruling out the diagnosis.

[/accordion_item][accordion_item title=”Disposition”]Discharge

  • I have asked the patient to return to the ED should if their symptoms worsen or should they develop difficulty with breathing.

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