Case 24
Esta es la nota de un caso de práctica para el USMLE CS típico.
Rojas aquí.
24 year-old woman complains of weakness. T: 32.7 C, BP: 115/77 mmHg, HR: 67/min, RR: 16/min
History
When did your problem start? When were you last perfectly healthy? Is it constant? Is it getting better? Comes and goes? Do you feel week in general or only in certain parts of your body? Is it more like fatigue or malaise? Have you had anything like this in the past? What do you think is causing your problem? What makes it worse or better? Position, exertion, time of the day, a particular environment, food, medications? Have you had fever, chills, headache, rash, nausea, vomiting, abdominal pain, diarrhea, constipation, shortness of breath, cough, bleeding, dysuria, cold intolerance, hair loss, dry skin, palpitations, anxiety, tremor, weight loss, sweating, poor concentration, blood in your stool, anal bleeding, increased or decreased appetite, insomnia, visual changes, focal weakness, dysphagia?.
Do you have any medical condition? Have you been hospitalized? Do you take medications? Do you take them as prescribed? Have you had surgery? Are you allergic to anything? Have you been screened for TB?
Do you smoke, drink alcohol or use drugs? What do you do for living? Have you travel recently? Do you have pets? Have you been around sick contacts lately? How is your appetite? Changes In diet? Changes in sleep paterns?
Are you married? Sexually active? Do you wear condoms consistently? Have you been diagnosed with an STD?
When was your last menstrual period? Are your cycles regular? How many days come in one of your cycles? DO you bleed heavily. Have you had children?
Is there any disease running in your family? Any problem with your parents or close relatives?
Exam
Wash hands
Neck
Neuro
Chest
Abdomen
Extremities
Patient Note
History
CC: 24 y/o female c/o asthenia
HPI: Started insidiously, and has progressed over 2 months. Progression. Generalized. Exacerbated when walking up and down stairs and when eating. Positive for diplopia, intial dysphagia (weak tongue and jaw). No fever, chills, cold intolerance, palpitations, hair loss, diarrhea, dysuria, arthralgia or recent illnesses. No rashes.
PMH. Non-contributory. She takes oral contraceptives. NKDA
FH: Mother with “neck gland problem”
SH: No tobacco, alcohol or drugs. No changes in appetite or weight loss. No insomnia. Mechanical engeneering student.
SexH: Single. Not sexually active.
Gyn: No metrorrhagia, LMP 2 weeks ago, no abnormalities.
Physical exam
VS: wnl
Gen. NAD, Comfortable.
HEENT. Atraumatic head PERRL. No ptosis. No fundoscopic changes.
Neck. Supple. No cervical, supraclavicular or axillary adenopathy. Non palplable thyroid gland.
Chest. Clear to auscultation. Normal heart sounds. No rubs, gallops or murmurs.
Abdomen. Soft, non tender, no guarding. No masses or hepatosplenomegaly. Timpanic in four quadrants. Normal bowel sounds.
Neuro: Alert, oriented x3, compliant with exam. Cranial nerve intact. Strenght 5/5 x4, DTR, 2/4 x4. No changes in somatosensation. No dysmetria. Negative Romberg. Negative babinski.
Extremities. No rashes, edema, clubbing or cyanosis. Normal skin hydration.
Differential Diagnosis
1. Myastenia gravis
2. Hypothyroidism
3. Iron deficiency anemia
4. Lambert-Eaton syndrome
5. Botulism
Diagnostic Workup
1. T4, TSH
2. Tensilon test, AchR autoantibodies, Ca channel Ab
3. WBC, differential, hematocrit, hemoglobin, glucose, BUN, creatinine
4. CXR
5. Nerve conduction studies
posted by Julio @ 9:47 p.m.
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