Case Study 29: Diplopia and Weakness - CRASH! Medical Review Series

(Disclaimer: The medical information contained herein is intended for physician medical licensing exam review purposes only, and are not intended for diagnosis of any illness. If you think you may be suffering from any medical condition, you should consult your physician or seek immediate medical attention.)

[woloabel]

(On Tuesday of February 28, 2023). On the Matter of Case Study 29 on the Subject of Diplopia (Double Vision) and Weakness (Asthenia): 1) Vitals: 1) BP 114/73; 2) HR is 65; 3) RR is 12; 4) T is 97/2*F; 5) Sat is 100% RA; and 6) BMI is 21.1 (Normal Range is 18.5 to 24.9); 2) Signs And Symptoms (SSx): 1) Diplopia/Double Vision; 2) Myasthenia/Asthenia; 3) Family History Positive For Rheumatoid Arthritis (RA) in a Sibling; 4) Medications on File are Levonorgestrel Intrauterine Device (IUD) and Multivitamins; 5) Myasthenia Gravis SSx: 1) Varying degrees of Myasthenia (Face, Limbs and Progressively Worse On Exertion), 2) Diplopia (double vision), 3) Blepharoptosis or Ptosis (Drooping Eyelids), 4) Dysarthria (Trouble Talking), 5) Dysphagia (Trouble Swallowing); 6) Apnea/Dyspnea (Respiratory Muscles Affected Ultimately); 7) Dyskinesia (As in Gait and Voluntary Limb Muscle Weakness); 3) Physical Examination (Px): 1) General is Significant with Fatigue (A progressive Weakness and Amelioration with Rest) otherwise Well Developed, Well Nourished, No Acute Distress (WD-WN-NAD); 2) HEENT is marked by Bilateral Blepharoptosis (Bi-Palpebral Ptosis); Snellen is 20/4) Oculus Sinister (OD) and Oculus Dexter (OD); Otherwise Atraumatic Normocephalic, Funduscopic Visualization Unremarkable, PERRLA, Extraocular Movement (EOM) Ordered, Supple Neck, Thyroid Normal, and LAN Negative (Absence of Swelling therein); 3) Chest and Lungs are Clear on Auscultation (Apnea/Dyspnea Unlikely); 4) CV is RRR and without Abnormal Sounds (Murmur and Gallops); 5) Abdomen is Soft, NT/ND, and Normal Bowel Sounds (NBS); 6) Neurology is Significant for Muscle Strength Alternations from +5/5 in all Extremities to +3/5 after a Couple of Minute Pause on Re-Examination; Weakness is Noticed On Eye Closure (Otherwise CNs Normal); Normal DTRs (No Hyperactivity or Hyperreflexia); 4) DDx: 1) Myasthenia Gravis (MG); 2) Lambert-Eaton Myasthenic Syndrome (LEMS) is specific to Anti-Voltage-Gated Calcium Channels (VGCC) Antibodies and with Chest CT Screening Malignancy is the Primary Morphology Assessment Intention; 3) Botulism is Specific To Nerves and can affect the Muscles Similar to MG (but Paralysis is most Likely). Mydriasis (Pupil Dilation), Hypotension, Bradycardia, Constipation, And Urinary Retention; 4) Hypothyroidism is characterized by a General Asthenia without predominate pathologic Activity to Bulbar and Ocular Muscles; 5) Diagnosis (Dx): 1) Serum Acetylcholine Receptor Antibody Test (90% Specific to MG; Serology herein is Positive); if Negative and MG is still Likely Muscle Specific Kinase (MuSK) Antibody Assay via Serology is Indicated; 2) Electromyography (EMG) shows Decreasing Response Amplitude Upon Repetitive Stimulation; 3) Thyroid Stimulating Hormone (TSH) is WNL; 4) Further Investigation on Known Associations and/or Specific Structural Abnormality: a) CT Chest and b) TSH if not yet Performed (Thymus Hyperplasia Or Thymoma at 10% of Cases); 5) 6) Treatment (Tx): 1) Acetylcholinesterase Inhibitor (Pyridostigmine, Neostigmine); 2) Adjunctive Pharmacotherapy is Glucocorticosteroids with Osteoporosis Prophylaxis with a Bisphosphonate (or Hormone Replacement Therapy [HRT]); 3) Immunosuppressants (Azathioprine A Purine Analogue Drug Class); 4) Thymic Features merit and/or Refractory (ineffective Drug Therapy) warrants Thymectomy (General Surgery Consult); 5) Respiratory Distress/Myasthenia Crisis warrants Plasmapheresis or Plasma Exchange (PLEX); 1) Intravenous Immunoglobulin (IVIG); 2) Intubation with Propofol Sedation is Possible (Diaphragmatic and Intercoastal Muscle Weakness or Severe Life-threatening Muscle Weakness; Avoiding Muscle Cessation); 6) Referral To Neurology For Long-Term Management is Standard of Care (SOC); 7) Management (Mx): 1) Myasthenic Crisis (Dyspnea, Shortness of Breath, Tachypnea); 2) Technicality of Respiratory Distress: 1) Forced Vital Capacity (FVC) in the Range of 10-15mL/kg or Less is Generally Agreed to Be Deadly if not Treated by Mechanical Ventilation Therapy (Management therein); 3) Admission; 4) Plasmapheresis and/or 5) Intravenous Immunoglobulin (IVIG); MD Paul W. Bolin, es geht sehr, sehr gut und wuensch du auch Schweinen Haette weil ich viel habe. Heil!

[waelfadlallah]

May i know the mechanism of action of IVIG ?

[QuizmasterLaw]

I have monocular diplopia, can that be a symptom of diabetes? or is it "just" dry eye?