Difference between revisions of "Weakness"

(Physical Exam)
 
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**Sudden onset of severe headache? [[SAH]]
 
**Sudden onset of severe headache? [[SAH]]
 
**Trauma? Epidural or [[Subdural Hematoma]]
 
**Trauma? Epidural or [[Subdural Hematoma]]
**Severe migratory neck or chest pain? [[vertebral and carotid dissection|Arterial dissection syndromes]]  
+
**Severe migratory neck or chest pain? [[vertebral and carotid artery dissection|Arterial dissection syndromes]]  
 
*'''Temporal pattern to weakness? Fluctuating or fixed weakness?'''  
 
*'''Temporal pattern to weakness? Fluctuating or fixed weakness?'''  
 
**Weakness with repetitive motions? Neuromuscular junction pathology like [[Myasthenia Gravis]]
 
**Weakness with repetitive motions? Neuromuscular junction pathology like [[Myasthenia Gravis]]
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**[[visual disturbances|Vision changes]]: Posterior circulation [[stroke]], [[Myasthenia Gravis]]
 
**[[visual disturbances|Vision changes]]: Posterior circulation [[stroke]], [[Myasthenia Gravis]]
 
**[[Shortness of breath]]: cardiovascular etiology
 
**[[Shortness of breath]]: cardiovascular etiology
**[[Chest pain]] or [[neck pain]]: Acute [[vertebral and carotid dissection|carotid/vertebral]]/[[aortic dissection]], [[AMI]]
+
**[[Chest pain]] or [[neck pain]]: Acute [[vertebral and carotid artery dissection|carotid/vertebral]]/[[aortic dissection]], [[AMI]]
 
**[[abdominal pain|Abdominal]] or [[back pain]]:
 
**[[abdominal pain|Abdominal]] or [[back pain]]:
 
***with alteration of bowel habits? [[Botulism]], organophosphate poisoning, toxins, [[Guillain-Barre Syndrome]], [[Electrolyte Imbalance]].  
 
***with alteration of bowel habits? [[Botulism]], organophosphate poisoning, toxins, [[Guillain-Barre Syndrome]], [[Electrolyte Imbalance]].  
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| '''End-plate/muscle'''||||||||||
 
| '''End-plate/muscle'''||||||||||
 
|-
 
|-
| Motor end plate||Ooccular,bulbar and descends, fatigable ||No||Nl/diminished||Nl/parethesias||No
+
| Motor end plate||Ocular, bulbar and descends, fatigable ||No||Nl/diminished||Nl/parethesias||No
 
|-
 
|-
 
| Muscle||Proximal > distal ||No||Nl/diminished||Normal||+/-
 
| Muscle||Proximal > distal ||No||Nl/diminished||Normal||+/-

Latest revision as of 16:08, 4 March 2020

Background

Determine if patient has actual neuromuscular weakness (suggesting CNS dysfunction) or non-neuromuscular weakness.

Clinical Features

History

Physical Exam

Focus on clarifying if patient has true loss of strength and determining distribution of deficits. Check for trauma, carotid bruits, thyroid enlargement, irregular rhythm, unequal pulses, rashes or ticks.

Location Weakness Bowel/Bladder Reflexes Sensory Pain
Upper motor neuron
Brain Variable Increased Diminished No
Brainstem "crossed" findings - ipsilateral cranial nerve weakness and contralateral hemiparesis
Cord Fixed level Yes Increased Diminished +/-
Lower motor neuron
Nerve Distal > proximal and ascends No Diminished Nl/parethesias No
End-plate/muscle
Motor end plate Ocular, bulbar and descends, fatigable No Nl/diminished Nl/parethesias No
Muscle Proximal > distal No Nl/diminished Normal +/-

Differential Diagnosis

Weakness

Evaluation

Workup

On all patients:

Consider:

  • CK (mypoathies)
  • ESR
  • CXR and UA (if infectious symptoms or elderly)
  • FVC (if evidence of respiratory compromise, i.e. Myasthenia, GBS)
  • CT head (if focal findings, altered mental status, history of cancer, history of any trauma in patient on anticoagulation)
  • LP (CNS infection, GBS)

Management

Intubation Indications

  • Severe fatigue
  • Inability protect airway
  • Rapidly increasing PaCO2
  • Hypoxemia despite O2
  • FVC <12 mL/kg
  • Neg Insp Force <20 cm H2O

Disposition

  • Depends on process
    • If normal initial workup, make sure has no respiratory compromise

See Also

External Links

References