1. NEUROPATHY Subsection B3 Francisco – Go, Kerby + Laxamana September 16, 2009

2. NEUROPATHY CASE General data: 22 year old, female Chief Complaint: Fatigue and Generalized weakness 2 months PTR mild fatigue after exercising at the gym change in voice after talking for several minutes Several days PTR intermittent double vision left eye drooping - late in the day

3. NEUROPATHY CASE Physical Examination mild L ptosis - fatigued 1 min upgaze no weakness of extraocular or bulbofacial muscles voice: normalmuscle bulk and tone: normal mild weakness of both upper and lower extremity proximal muscles including neck extensor DTR and sensation: normal

4. SALIENT FEATURES 22 year old Female Fatigue Generalized weakness Mild fatigue after exercising Change in voice after talking for several minutes Intermittent double vision Left eye drooping late in the day

5. SALIENT FEATURES Mild left ptosis - fatigued with one minute of upgaze (-) weakness of extraocular or bulbofacial muscles Voice, muscle bulk and tone, DTR and sensation: normal. Mild weakness of both upper and lower extremity proximal muscles including neck extensors

6. DIFFERENTIAL DIAGNOSIS 1. What is the most likely diagnosis? a. Lambert-Eaton Myasthenic Syndrome b. Myasthenia Gravis c. Botulism d. Organophosphate poisoning

7. Botulism CLINICAL FEATURES

8. Organophosphate Poisoning CLINICAL FEATURES

9. Lambert-Eaton Myasthenic Syndrome CLINICAL FEATURES progressive weakness – (-) involvement of respiratory and facial muscles affected ocular and respiratory muscles - not as severe as MG tend to be worse in the MORNING IMPROVE with exercise and nerve stimulation PROXIMAL parts of the legs and arms are predominantly affected autonomic symptoms like dry mouth or impotence reflexes are usually REDUCED OR ABSENT

10. Myasthenia Gravis CLINICAL FEATURES CARDINAL FEATURE: weakness and fatigability of muscles increased weakness – during REPEATED USE/EXERCISE IMPROVED with rest or sleep cranial muscle involvement (lids and EOM) – diplopia and ptosis speech – nasal timbre – weakness of the palate dysarthric “mushy” quality – weakness of the tongue limb weakness – proximal and asymmetric PRESERVED DTR

12. CLINICAL IMPRESSION Neuromuscular disorder secondary to Myasthenia Gravis