Weakness: Difference between revisions

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==Diagnosis==
==Diagnosis==
===UPPER MOTOR NEURON===
===UPPER MOTOR NEURON===
# BRAIN
* BRAIN
*Weakness - variable
**Weakness - variable
*Bowel/Bladder -
**Bowel/Bladder -
*Reflexes - increased
**Reflexes - increased
*Sens - diminished
**Sens - diminished
*Pain - no
**Pain - no
*Asymmetric/unilateral
**Asymmetric/unilateral
# CORD
* CORD
*Weakness - fixed level
**Weakness - fixed level
**Bowel/Bladder - YES
**Reflexes - increased
**Sens - diminished
**Pain - +/-


    Bowel/Bladder - YES
===LOWER MOTOR NEURON===
* NERVE
**Weakness - distal and ascends
**Bowel/Bladder - NO
**Reflexes - diminished
**Sens - nl/paresthesias
**Pain - no


    Reflexes - increased
===END-PLATE/MUSCLE===
* MOTOR END PLATE
**Weakness - head and descends
**Bowel/Bladder - NO
**Reflexes - nl/diminished
**Sens - nl
**Pain - no
*MUSCLE
**Weakness - proximal
**Bowel/Bladder - NO
**Reflexes - nl/diminished
**Sens - nl
**Pain - +/-


    Sens - diminished
==DDX==
# UPPER
## Multiple sclerosis
## Poliomyelitis
## ALS (upper & lower motor)
# CORD
## Painful
### Cord compression
## Painless
### Transverse myelitis
### Spinal cord infarct
### Intramedullary tumor
# NERVE
## Guillian-Barre
## Toxic neuropthy (Ciguatera)
## Tick paralysis
## Diabetic neuropathy
## Porphyria
# MOTOR END PLATE
## Myasthenia gravis
## Botulism (descending)
## Organophosphate poisoning
## Lambert-Eaton
# MUSCLE
## Painful
### Rhabdo
### Alcoholic
### Myopathy
### Polymyositis
### Dermatomyositis
### Toxins
### Hypophos
### Hypo-kalemia
### Polymyalgia rheum
## Painless
### Familial periodic paralysis
### Endocrine
# MIXED
## Upper & Lower Motor Neuron
### ALS
## Sensory & Motor
###
# NON-NEUROMUSCULAR
## MI
## Resp failure
## Sepsis
## Dehydration
## Anxiety
## Fibromyalgia/chronic fatigue
## Malignancy


    Pain - +/-
==EMERGENT THREAT/ED WORKUP==
 
# CORD
## paralysis
 
## MRI, neurologist
LOWER MOTOR NEURON
# NERVE
 
## resp failure
III. NERVE
## FEV1, airway mgt, ticks?, neurologist
 
# MOTOR END PLATE
    Weakness - distal and ascends
## resp failure
 
## FEV1, airway mgt, Tensilon Test?
    Bowel/Bladder - NO
# MUSCLE
 
## Rhabdo
    Reflexes - diminished
## urine myoglobin, serum CK, BUN/Cr
 
## serum K+
    Sens - nl/paresthesias
 
    Pain - no
 
 
END-PLATE/MUSCLE
 
IV. MOTOR END PLATE
 
    Weakness - head and descends
 
    Bowel/Bladder - NO
 
    Reflexes - nl/diminished
 
    Sens - nl
 
    Pain - no
 
 
V. MUSCLE
 
    Weakness - proximal
 
    Bowel/Bladder - NO
 
    Reflexes - nl/diminished
 
    Sens - nl
 
    Pain - +/-
 
 
DIFFERENTIAL DIAGNOSIS
 
I. UPPER
 
    A) Multiple sclerosis
 
    B) Poliomyelitis
 
    C) ALS (upper & lower motor)
 
II. CORD
 
    A) Painful
 
          i) Cord compression
 
    B) Painless
 
          i) Transverse myelitis
 
          ii) Spinal cord infarct
 
          iii) Intramedullary tumor
 
III. NERVE
 
    A) Guillian-Barre
 
    B) Toxic neuropthy (Ciguatera)


    C) Tick paralysis
===INTUBATION INDICATIONS===
 
# Severe fatigue
    D) Diabetic neuropathy
# Inability protect airway
 
# Rapidly increasing PaCO2
    E) Porphyria
# Hypoxemia despite O2
 
# FVC <12 mL/kg
IV. MOTOR END PLATE
# Neg Insp Force <20 cm H2O
 
    A) Myasthenia gravis
 
    B) Botulism (descending)
 
    C) Organophosphate poisoning
 
    D) Lambert-Eaton
 
V. MUSCLE
 
    A) Painful
 
          i) Rhabdo
 
          ii) Alcoholic
 
          iii) Myopathy
 
          iv) Polymyositis
 
          v) Dermatomyositis
 
          vi) Toxins
 
          vii) Hypophos
 
          viii) Hypo-kalemia
 
          ix) Polymyalgia rheum
 
    B) Painless
 
          i) Familial periodic paralysis
 
          ii) Endocrine
 
VI. MIXED
 
    A) Upper & Lower Motor Neuron
 
          i) ALS
 
    B) Sensory & Motor
 
          i)
 
VII. NON-NEUROMUSCULAR
 
    A) MI
 
    B) Resp failure
 
    C) Sepsis
 
    D) Dehydration
 
    E) Anxiety
 
    F) Fibromyalgia/chronic fatigue
 
    G) Malignancy
 
 
EMERGENT THREAT/ED WORKUP
 
I. CORD
 
    - paralysis
 
    - MRI, neurologist
 
2. NERVE
 
    - resp failure
 
    - FEV1, airway mgt, ticks?, neurologist
 
3. MOTOR END PLATE
 
    - resp failure
 
    - FEV1, airway mgt, Tensilon Test?
 
4. MUSCLE
 
    - Rhabdo
 
    - urine myoglobin, serum CK, BUN/Cr
 
    serum K+
 
 
INTUBATION INDICATIONS
 
1) Severe fatigue
 
2) Inability protect airway
 
3) Rapidly increasing PaCO2
 
4) Hypoxemia despite O2
 
5) FVC <12 mL/kg
 
6) Neg Insp Force <20 cm H2O
 


==Source==
2/26/06 DONALDSON (adapted from Rosen, Lampe, Birnbaumer)
2/26/06 DONALDSON (adapted from Rosen, Lampe, Birnbaumer)


adapted from Hockberger
adapted from Hockberger


[[Category:Neuro]]
[[Category:Neuro]]

Revision as of 23:27, 28 March 2011

Background

Acute/Generalized

Workup

  1. cbc
  2. chem 10 (esp. K, Mg, Ca, Phos)
  3. ecg
  4. +/- CK (r/o myopathy)
  5. +/- FVC (eval impending resp failure, i.e. Myasthenia)
  6. +/- ABG/CT/LP/TSH/UA (rhabdo)

Diagnosis

UPPER MOTOR NEURON

  • BRAIN
    • Weakness - variable
    • Bowel/Bladder -
    • Reflexes - increased
    • Sens - diminished
    • Pain - no
    • Asymmetric/unilateral
  • CORD
    • Weakness - fixed level
    • Bowel/Bladder - YES
    • Reflexes - increased
    • Sens - diminished
    • Pain - +/-

LOWER MOTOR NEURON

  • NERVE
    • Weakness - distal and ascends
    • Bowel/Bladder - NO
    • Reflexes - diminished
    • Sens - nl/paresthesias
    • Pain - no

END-PLATE/MUSCLE

  • MOTOR END PLATE
    • Weakness - head and descends
    • Bowel/Bladder - NO
    • Reflexes - nl/diminished
    • Sens - nl
    • Pain - no
  • MUSCLE
    • Weakness - proximal
    • Bowel/Bladder - NO
    • Reflexes - nl/diminished
    • Sens - nl
    • Pain - +/-

DDX

  1. UPPER
    1. Multiple sclerosis
    2. Poliomyelitis
    3. ALS (upper & lower motor)
  2. CORD
    1. Painful
      1. Cord compression
    2. Painless
      1. Transverse myelitis
      2. Spinal cord infarct
      3. Intramedullary tumor
  3. NERVE
    1. Guillian-Barre
    2. Toxic neuropthy (Ciguatera)
    3. Tick paralysis
    4. Diabetic neuropathy
    5. Porphyria
  4. MOTOR END PLATE
    1. Myasthenia gravis
    2. Botulism (descending)
    3. Organophosphate poisoning
    4. Lambert-Eaton
  5. MUSCLE
    1. Painful
      1. Rhabdo
      2. Alcoholic
      3. Myopathy
      4. Polymyositis
      5. Dermatomyositis
      6. Toxins
      7. Hypophos
      8. Hypo-kalemia
      9. Polymyalgia rheum
    2. Painless
      1. Familial periodic paralysis
      2. Endocrine
  6. MIXED
    1. Upper & Lower Motor Neuron
      1. ALS
    2. Sensory & Motor
  7. NON-NEUROMUSCULAR
    1. MI
    2. Resp failure
    3. Sepsis
    4. Dehydration
    5. Anxiety
    6. Fibromyalgia/chronic fatigue
    7. Malignancy

EMERGENT THREAT/ED WORKUP

  1. CORD
    1. paralysis
    2. MRI, neurologist
  2. NERVE
    1. resp failure
    2. FEV1, airway mgt, ticks?, neurologist
  3. MOTOR END PLATE
    1. resp failure
    2. FEV1, airway mgt, Tensilon Test?
  4. MUSCLE
    1. Rhabdo
    2. urine myoglobin, serum CK, BUN/Cr
    3. serum K+

INTUBATION INDICATIONS

  1. Severe fatigue
  2. Inability protect airway
  3. Rapidly increasing PaCO2
  4. Hypoxemia despite O2
  5. FVC <12 mL/kg
  6. Neg Insp Force <20 cm H2O

Source

2/26/06 DONALDSON (adapted from Rosen, Lampe, Birnbaumer)

adapted from Hockberger

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