Differential diagnosis and mini-cases - LoC, Numbness and weakness, Fatigue/sleepiness, Night sweats, Insomnia Flashcards
Loss of consciousness - key history ?
- Presence or absence of preceding symptoms (nausea, diaphoresis, palpitations, pallor, lightheadedness, pain) ?
- Context (exertional, postural, traumatic; stressful, painful, claustrophobic experience; dehydration) ?
- Associated tongue biting or incontinence, tonic-clonic movements, prolonged confusion;
- Asssociated : dyspnea, pulmonary embolism risk factors ?
- History of heart disease, arrhythmia, hypertension, or diabetes; alcohol and drug use ?
Loss of consciousness - key physical findings ?
- Vital signs, including orthostatics;
- Complete neurologic exam;
- Carotid and cardiac exam;
- Lung exam;
- Exam of the lower extremities.
What is your differential diagnosis and workup ?
“26 yo M presents after falling and losing consciousness at work. He had rhythmic movements of the limbs, bit his tongue, and lost control of his bladder. He was subsequently confused after regaining consciousness (as witnessed by his colleagues)”
- Differential diagnosis :
- Seizures - generalized tonic clonic seizure
- Convulsive syncope
- Substance abuse/overdose
- Malingering
- Hypoglycemia
- Workup :
- CB, Electrolytes, glucose
- Urine toxicology
- EEG
- MRI—brain, CT—head
- LP—CSF analysis
- ECG
What is your differential diagnosis and workup ?
“55 yo M c/o falling after feeling dizzy and unsteady. He experienced transient loss of consciousness. His past medical history is significant for hypertension and diabetes mellitus”
- Differential diagnosis :
- Drug-induced orthostatic hypotension
- Hypoglycemia
- Hyperosmolar, hyperglycemic state
- Cardiac arrythmia
- Vadovagal syncope
- Seizure
- TIA, Stroke
- MI, PE
- Hypoxia
- Workup :
- CBC with differential
- ECG, echocardiography
- Blood gasometry, glucose, electrolytes
- CT head, MRI brain, angiography
- CXR
- D-dimers
What is your differential diagnosis and workup plan ?
“65 yo M presents after falling and losing conscious- ness for a few seconds. He had no warning before passing out but recently had palpitations. His history includes a coronary artery bypass graft”
- Differential diagnosis :
- Cardiac arrythmia
- Severe aortic stenosis
- AMI
- Hypoxia - heart failure
- Vasovagal syncope
- Seizure
- Pulmonary embolism
- Workup :
- ECG
- Holter monitoring
- CBC
- Electrolytes, glucose
- Echocardiography
- CT—head
What is the key history for : numbness / weakness ?
- Distribution (unilateral, bilateral, proximal, distal),
- Duration, ± progression,
- Pain (especially headache, neck or back pain);
- Constitutional symptoms,
- Other neurologic symptoms;
- History of diabetes, alcoholism, atherosclerotic vascular disease.
What are the key physical exam manouvers in case of weakness/numbness ?
- Vital signs;
- Neurologic and musculoskeletal exams;
- Relevant vascular exam.
What is your differential diagnosis and workup ?
“68 yo M presents following a 20-minute episode of slurred speech, right facial drooping and numbness, and right hand weakness. His symptoms had totally resolved by the time he got to the emergency de- partment. He has a history of hypertension, diabetes mellitus, and heavy smoking”
Differential diagnosis
- TIA
- Seizure
- Stroke
- Hypoxia
- Hypoglycemia
- Facial nerve palsy
Workup
- CT-brain, angiography
- CBC with differential
- Echocardiography
- EEG
- ECG
- Blood gasometry
- Fasting lipid panel
- Glucose, electrolytes, BUN, Creatinine
- Nerve conduction studies - facial nerve
- Doppler - U/S - carotid
What is your differential diagnosis and workup ?
“68 yo M presents with slurred speech, right facial drooping and numbness, and right hand weakness. Babinski’s sign is present on the right. He has a his- tory of hypertension, diabetes mellitus, and heavy smoking”
Differential diagnosis
- Stroke
- TIA
- Seizure
- Intracranial neoplasm
- Subdural or epidural hematoma
Workup
- CT—head
- CBC
- Electrolytes PT/PTT/INR
- Fasting lipid panel
- MRI—brain
- Doppler U/S—carotid
- Echocardiography
- ECG
What is your differential diagnosis and workup ?
“33 yo F presents with ascending loss of strength in her lower legs over the past 2 weeks. She had a re- cent URI”
Differential diagnosis
- Guillain-Barre syndrome
- Polymiositis
- Mulitiple sclerosis
- Myasthenia gravis
- Peripheral neuropathy
- Tumor in the vertebral canal
- Transverse myelitis
Workup
- CBC, electrolytes, AST/ALT
- Nerve conduction studies
- Needle electromyography
- LP - OP, CSF exam - glucose, proteins, cellularity
- Creatinine Kinase (CPK), Aldolase
- Anti-Jo1 antibody screen
- CRP, ESR
- Edrophonium test
- TSH, T4, serum B12
- MRI-spine
What is your differential diagnosis and workup ?
“30 yo F presents with weakness, loss of sensation, and tingling in her left leg that started this morning. She is also experiencing right eye pain, decreased vi- sion, and double vision. She reports feeling “electric shocks” down her spine upon flexing her head”
Differential diagnosis
- Multiple sclerosis
- Myasthenia gravis
- Stroke
- Conversion disorder
- Malingering
- Intracranial mass
- Neurosyphilis
- Syringomyelia
- Transverse myelitis
- CNS vasculitis
Workup
- CBC, ESR
- VDRL/RPR
- MRI—brain
- spine LP—CSF analysis
- Retinal evoked potentials
What is your differential diagnosis and workup ?
“55 yo M presents with tingling and numbness in his hands and feet (glove-and-stocking distribution) for the past 2 months. He has a history of diabetes mellitus, hypertension, and alcoholism. There is decreased soft touch, vibratory, and position sense in the feet”
Differential diagnosis
- Peripheral neuropathy - DM2
- Peripheral neuropathy - B12 defficiency
- Alcoholic peripheral neuropathy
- Peripheral neuropathy - uremic
- Hypocalcemia
- Hyperventilation
- Paraproteinemia/myeloma
Workup
- HbA1c
- ESR
- Calcium
- Serum B12
- UA
- Serum and urine protein electrophoresis
What is your differential diagnosis and workup ?
“40 yo F presents with occasional double vision and droopy eyelids at night with normalization by morning”
Differential diagnosis
- Myasthenia gravis
- Lambert-Eaton syndrome
- Horner’s syndrome
- IIIrd nerve palsy
- Multiple sclerosis
- ALS
Workup
- Tensilon (edrophonium) test
- Serum ACh receptor antibodies
- CXR
- CT—chest
- MRI—brain
- EMG
What is your differential diagnosis and workup ?
“25 yo M presents with hemiparesis after a tonic-clonic seizure that resolved within a few hours”
Differential diagnosis
- Todd’s paralysis
- TIA
- Stroke
- Complicated migraine
- Malingering
Workup
- CBC
- Electrolytes
- EEG
- MRI—brain
- Doppler U/S—carotid
What is your differential diagnosis and workup ?
“56 yo obese F c/o tingling and numbness of her thumb, index finger, and middle finger for the past 5 months. Her symptoms are constant, have pro- gressively worsened, and are relieved with rest. She works as a secretary. She has a history of fatigue and a 20-lb (9-kg) weight gain over the same period”
Differential diagnosis :
- Carpal tunnel syndrome secondary to hypothyroidism
- Overuse injury of median nerve
- Medial epicondylitis
Workup
- Phalen’s maneuver and Tinel’s sign
- Nerve conduction studies
- TSH
- CBC