Weakness and Dizziness 377Questions 352 to 353
352.A 35-year-old woman presents to the ED complaining of left arm
weakness and right facial pain for 1 day. She denies any past medical history,
but on the review of systems remembers having pain and decreased vision
in her left eye approximately 4 months ago that has since resolved. She
attributed it to being stressed and tired and did not see a physician at the
time. Her BP is 126/75 mm Hg, HR is 76 beats per minute, temperature is
98.8°F, and RR is 12 breaths per minute. The physical examination is unre-
markable except for 4/5 strength in the left upper extremity. Which of the
following is the most likely diagnosis?
a. Myasthenia gravis
b. Multiple sclerosis (MS)
c. Vertebrobasilar artery occlusion
d. Encephalitis
e. Guillain-Barré syndrome
353.Which of the following is the best test to confirm your diagnosis in the
previous question?
a. Edrophonium test
b. Angiogram of the carotid arteries
c. Lumbar puncture (LP) and cerebrospinal fluid (CSF) analysis
d. Obtain a head CT
e. Obtain a head magnetic resonance imaging (MRI)
354.A 58-year-old woman is brought to the ED by paramedics complain-
ing of worsening left arm and leg weakness. She reports a history of hyper-
tension,diabetes, and smoking. She denies any past surgeries. Her BP is
165/83 mm Hg, HR is 110 beats per minute, temperature is 98.4°F, RR is
18 breaths per minute, pulse oxymetry is 98% on room air, and capillary glu-
cose is 147 mg/dL. On examination, the patient’s speech is slurred and you
notice a left-sided facial droop. Her left arm and leg strength is 2/5 and
there is decreasedsensation.The patient’s head CT is normal. It has been
130 minutes since the onset of symptoms. Which of the following is the most
appropriate next step in management?
a. Observation since she is out of the thrombolytic window.
b. Administer nitroprusside to lower her BP then give thrombolytics.
c. Administer heparin only since she is out of the thrombolytic window.
d. Administer thrombolytic therapy.
e. Administer aspirin only since she is out of the thrombolytic window.