Case Presentation 2

Hello hello!

So I have a few case reports/presentations that I will be posting. I actually have to present cases while I am on Wards/inpatient medicine at least once a month, sometimes more. I have decided to share what I’ve actually presented. These may be easy for you, or they may be challenging.

I challenge you to look at each section, and then think about what this could be and a list of possible differential diagnoses for the new information gathered each time. Stop at each stop sign and see if you can answer the questions below first before moving on.

HPI:

79 y/o F. Initially came to ED for generalized weakness, worse on R side, and L eyelid drooping. L>R

Duration: x3 weeks. Progressively worse.

Episodes: initially for 15 minutes, episodes have increased in length and frequency over last 3 weeks.

Generalized weakness initially noted in the early evening particularly notable with ambulating. Now becoming more frequent.

Associated symptoms: Intermittent blurriness to L eye. No dysphagia or aphasia. Intermittent headaches, and lightheadedness. Developed DIB.

Other: large amount of stress.

Also had a fall to L hip. No HI or LOC.  No blood thinners.

Think about what your differentials could be?

What are you most concerned about? What do you need to rule out first? What will kill the patient and needs to be addressed right away?

Then you can add anything additional such as other common diagnoses, rare diagnoses, etc.

HISTORY:

PMHx: Anemia, DM, HTN, a fib/Sick sinus syndrome s/p pacemaker, dyslipidemia, PUD, hypothyroidism, chronic pain

PSHx: cholecystectomy, hysterectomy, pacemaker

FamHx: CVA/TIA, CVD. Daughter has MS

Sochx: no Etoh, drugs, or smoking

All: augmentin- rash; latex-rash

Home meds: furosemide, levothyroxine, glimepiride, gabapentin, norco, sertraline, carvedilol, losartan, pantoprazole, zolpidem, ASA 81

Differentials that my colleagues came up with:

  • CVA
  • MS
  • brain mass
  • inflammatory neuro disorder
  • MG
  • Lambert eaton
  • Guillan-barre
  • 3rd nerve palsy
  • malingering
  • conversion disorder

Vitals in ED: 97.7’F, 61 BPM,  RR 18, 105/55- 172/83, 95% RA

Exam:  ptosis L>R, a fib regular rate. Pacemaker in L upper chest wall. End expiratory wheezing throughout. Neuro: CN II-XII intact. Normal speech. Patellar reflexes 2+. Motor 5/5 BUE and LE. Anxious. Remainder of exam is within normal limits.

Look at your differential list. Is there anything you want to cross off? Anything you want to add?

Do you want to move a diagnosis up or down? What is more likely with this new information?

What type of labs or imaging do you want to order?

LABS/IMAGING:

CT head: no acute intracranial pathology

CXR: negative

L hip xray: negative

Electrolytes: Na-140, K 3.7, Cl 102, bicarb 31, BUN 31, Cr 1.3, glucose 75, Ca 9.6; LFT’s normal

Trop x2 negative, BNP 92

Coags normal

CBC: WBC 7.0, Hgb 11.9, Hct 36.3, MCV 89.6, plt 223

TSH- 1.14, normal

Lipid panel: triglycerides 146, cholesterol 163, LDL 94, HDL 40

CRP: negative, <0.4

COVID negative

B12: >1000

Folate: normal, 12.3

MRI brain: negative

Again, are there any diagnoses on your list that you can cross off, add anything new, or move to more likely/less likely?

At this point, we still don’t have an exact diagnosis and patient is not improving. What other special labs or imaging can you order to help you determine what it is?

Additional testing:

EBV panel: IgG and nuclear antigen Ab +. IgM and early antigen Ab negative.

AchR-Ab panel: + 3.34

Head CTA: essentially normal

Chest CT: small L basilar effusion, small hiatal hernia, atelectasis in lower lobes

COURSE:

Patient remained very anxious and short of breath. Oxygen and hydroxyzine greatly helped her dyspnea symptoms. Dyspnea is likely anxiety given her current situation of being in the hospital and not knowing what is going on, and her increased stress level from her home life.

CONSULTS:

Neurology: Wanted to rule out MG, 3rd nerve palsy, neuromuscular disorder, GBS. Their testing was added above.

What do you think the diagnosis is?

DIAGNOSIS:

  1. Myasthenia Gravis
  2. Anxiety secondary to stress

What is the treatment for Myasthenia Gravis?

ANSWER:

Started on Pyridostigmine/Mestinon with improvement of ptosis and weakness symptoms.

So, I hope you enjoyed this layout. This is exactly how we have small learning sessions at my program and I hope you learned something! I also hope you started your journey or at least continued practicing your ability to put all the pieces together.

Until next time. Cheers!

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