Author: Brett Wilhoit, MD
Co Author #1: Alex Decastro, MD
Editor: Kristine Karlson, MD
18-year-old African-American male with no significant past medical history presents to ER with complaints of sudden onset diffuse muscle weakness that developed the day prior while exercising. He states that he was at basketball practice when he started to experience muscle aches and nausea. His symptoms progressed acutely that night to diffuse muscle weakness, resulting in the inability to walk or stand. He reports experiencing a similar episode the week prior, in which he experienced mild fatigue and cramping. Those symptoms resolved with rest and fluids. He endorses normal food and fluid intake. He has no previous illness, exposure, or travel.
PAST MEDICAL HISTORY: No significant past medical history.
PAST SURGICAL HISTORY: Appendectomy at age 13.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Unknown, as patient was adopted.
SOCIAL HISTORY: The patient denies any alcohol, tobacco, or illicit drug usage.
MEDICATIONS: No regularly scheduled prescription or over-the-counter medication use was reported.
REVIEW OF SYSTEMS: Positive for nausea, as well as diffuse non-focal weakness on date of admission. Denies any chest pain, palpitations, shortness of breath, fever, emesis, diarrhea, change in vision or change in urine color.
VITAL SIGNS: Temperature 98.7 Fahrenheit, heart rate 79, respiratory rate 16, oxygen saturation 100% on room air, blood pressure 121/74, height 5’10” and weight 64 kilograms.
GENERAL: No acute distress.
HEENT: Pupils equal, round, and reactive to light and accommodation. Head normocephalic without signs of trauma. Thyroid non-palpable. No cervical lymphadenopathy. Oropharynx without obvious lesions.
MUSCULOSKELETAL: Full range of motion in all extremities. Good muscle tone.
SKIN: Normal turgor.
NEURO: Alert and oriented to person, place, and time. No sensory deficits appreciated. Symmetrical weakness present: 3/5 strength bilaterally in upper extremities, 2/5 strength bilateral foot dorsiflexion, 2/5 strength bilateral lower extremities. Reflexes diminished in all extremities. Mental status normal.
PSYCH: Flat affect.
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