Author Question: A 33-year-old female complains of episodes of weakness of the left side of the face. Drooping of the ... (Read 32 times)

bio_gurl · **on:** Jun 25, 2018

A 33-year-old female complains of episodes of weakness of the left side of the face. Drooping of the left eyelid and weakness of the jaw muscle develops gradually throughout the day, and it is worse at night than the morning.

The patient has a medical-surgical history of cholecystectomy at age 30. Otherwise, patient has no history of illness and takes no medications. Denies use of tobacco or alcohol. On physical examination, vital signs are T 98 degrees, 18 resps/min, pulse 66, and BP 110/60. Ptosis of the left eyelid is noted. Vision: 20/20 os, 20/20 od, and 20/20 ou. Heart: regular rate and rhythm, no murmurs. Lungs are clear to auscultation. Abdomen is non-tender with no organomegaly. Extremities: Skin is pink, cool to touch, and intact bilaterally. Left and right quadriceps muscle strength 5/5. DTRs left and right + 2/4. No clonus. Negative Homan's and Babinski's sign. Sensation to pinprick and cotton ball intact in extremities and equal bilaterally. Dorsalis pedis pulses +1/4 bilaterally. Eyelids: left-sided ptosis. No facial droop. Left and right cheek sensation to pinprick and cotton ball intact. Masseter muscle: 2/5 left versus 5/5 on right. EOMs intact. Gag reflex: uvula midline gag intact. Shrug and sternocleidomastoid muscle strength 5/5 bilaterally. Tongue: midline and strength 5/5 bilaterally. The following disorder(s) should be considered in the diagnosis:
A. Bell's palsy
B. Stroke
C. Myasthenia gravis
D. Multiple sclerosis

Question 2

A patient with Crohn's disease complains of extreme muscle weakness, fatigue, diarrhea, bruising, 10-pound weight loss over the last few weeks, and dypnea on exertion.

On physical examination, the patient is afebrile, pulse 110, resps 20/min, and BP 100/ 50. BMI is 15. The patient is pale and frail looking, with bilateral ankle edema and bruises noted on cachetic thighs. Which of the following diagnostic tests is most helpful in the diagnosis of intestinal malabsorption?
A. Liver enzymes
B. Vitamin B12 assay
C. Stool for fat
D. INR

okolip · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: C
Myasthenia can occur at any age and may be associated with other autoimmune diseases. Limb weakness and fatigability of the affected muscles is a diagnostic sign. Symptoms are due to a variable blocking of neuromuscular transmission by autoantibodies that bind to acetylcholine receptors. Ocular, facial, masticatory, and pharyngeal muscles are most often affected. The eye symptoms of diplopia and ptosis are common early signs. Other symptoms include dysphagia, weakness in the extremities, and respiratory difficulties. Symptoms fluctuate during the day and the symptoms often relapse or remit over long periods of time, but ultimately the disease is progressive. Sustained activity of the affected muscles increases the weakness, and symptoms will improve with rest. Patients may require life support if respiratory effort is significantly affected.

Answer to Question 2

ANS: C
The signs and symptoms vary according to the underlying problem, but common symptoms include weight loss, flatulence, abdominal bloating, edema in the lower extremities resulting from protein deficiency, muscle weakness, possibly diarrhea or steatorrhea, dehydration, glossitis, and bruising. A variety of abnormal findings can be associated with malabsorption syndromes, including iron, folic acid, or B12 deficiency anemia; calcium deficiency; vitamins A, B, C, and D deficiencies; and niacin deficiency. A combination of weight loss, diarrhea, and anemia should raise the possibility of malabsorption. A variety of abnormal findings can be associated with malabsorption syndromes, including iron, folic acid, or B12 deficiency anemia; calcium deficiency; vitamins A, B, C, and D deficiencies; and niacin deficiency. There are as many diagnostics as there are causes of malabsorption. Measurement of fat in the stool is the most valuable diagnostic for diagnosing malabsorption, and a 3- to 4-day stool collection is advised. Stool specimens for ova, parasites and culture, and sensitivity will help to rule out infectious causes. Absorption tests, flat plate of the abdomen, upper GI with small bowel follow-through, endoscopy, and small bowel biopsy may be necessary for definitive diagnosis.