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Weakness

  • Common ddx

    • pinched nerve, diabetic neuropathy, B12, MG, hypothyroidism
  • Serious ddx

    • stroke, MS, ALS, botulism, toxic exposure, dermatomyositis, DMD
  • Labs

    • BMP to dx electrolyte abnormaties
    • glucuse to dx hypoglycemia
    • TSH to dx hypothyroidism
    • UA to dx myoglobinuria, rhabdomyolysis
    • CK to dx myopathy
    • MG panel or edrophonium test to dx MG
    • EMG to dx neuropathy
    • LP to dx GBS
    • head CT to dx stroke
    • MRI to dx MS, brain tumor
    • muscle biopsy to dx myopathy
  • Categorical ddx

    • neuropathy, NMJ dz, myopathy, CNS lesion, leukodystrophy, endocrine
  • Neuropathy ddx (sensory and motor sx)

    • Mononeuropathy: carpal tunnel, tarsal tunnel, ulnar neuropathy, radial neuropathy, pinched nerve
    • Polyneuropathy: GBS (ascending weakness, recent infection, hyporeflexia), MS (relapsing neuro sx, vision loss, ataxia), diabetic neuropathy (distal sensory loss), Charcot-Marie-Tooth (arched feet, foot drop), CIDP (chronic relapsing GBS), lead poisoning, B12 deficiency, diabetic neuropathy
  • Motor neuron dz (motor sx only, sensory intact)

    • ALS (upper & lower sx: Babinski, hyperreflexia, fasciculations)
    • polio (acute, paralysis, hyporeflexia)
    • spinal muscular atrophy (floppy baby, fasciculations)
  • NMJ dz (fatigable or facilitation, sensory intact)

    • MG (weakness worse with use)
    • Eaton-Lambert (weakness better with use)
    • Botulism (descending paralysis, floppy baby after eating honey)
    • pesticide exposure
  • Myopathy (proximal muscle weakness)

    • acquired: polymyositis (weakness, myalgia), dermatomyositis (rash), HIV, steroid
    • congenital (child): DMD (Gower's), Becker's (school age, Gower's), myotonic dystrophy (myotonia), McArdle's (exercise-induced cramps, dark urine, second wind), CPT II deficiency (exercise induced rhabdomyolysis), mitochondrial myopathy (ptosis, eye paresis, stroke-like episodes), facioscapulohumeral muscular dystrophy (face, scapula, humerus weakness)
  • CNS ddx

    • TIA, stroke (unilateral weakness), brain tumor (headache), myelopathy
  • Leukodystrophy ddx (child, mental retardation)

    • ALD, MLD, Krabbe's
  • Other ddx

    • hypothyroidism, hypoglycemia
  • HPI

    • onset
    • triggering events
    • location: proximal vs distal, unilateral vs bilateral, generalized vs specific
    • quality: fatigable vs facilitative, fatigue vs true muscle weakness, associated pain or paresthesia
    • severity: mild weakness vs paralysis, constant vs episodic, ability to walk, standing up without using arms
    • alleviates: time of day
    • aggravates: exercise, time of day
  • ROS

    • fever, weight loss
    • rash
    • headache, vision changes
    • sore throat, runny nose
    • chest pain, dyspnea, cough
    • nausea, vomiting, diarrhea, abdominal pain
    • dark urine
    • paresthesia, clumsiness
    • heat, cold sensitivity
  • PMH

    • recent infection
    • diabetes
    • HIV
  • FH

    • muscular dystrophy
  • SH

    • EtOH
    • diet: strict vegan diet
    • lead exposure
    • pesticide exposure
  • Meds

    • chronic steroid usage
  • Allergies

  • Px

    • vitals
    • gen impression
    • skin: rash, fasciculations
    • head: trauma
    • eyes: ptosis, EOM, pupils, papilledema, visual field
    • ENT: mucosal membrane, pharyngitis, thyroid
    • cardio, pulm, abd
    • neuro: strength, myotonia, reflex, sensation, finger-to-nose, gait
    • standing up without using hands

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