355.A 37-year-old woman presents to urgent care complaining of general
weakness and blurry vision over the last month. She states that she feels
great in the morning, but by dinner she has trouble cooking and complains
of double vision. Her husband notices that her eyelids sometimes look droopy
in the evening. On physical examination, her cranial nerves are intact, pupils
are equal and reactive, extraocular muscles are intact; however, you notice
slight ptosis. What is the most likely diagnosis of this patient?
a. Botulism
b. Lambert-Eaton myasthenic syndrome
c. Ophthalmoplegia of the third cranial nerve
d. Guillain-Barré syndrome
e. Myasthenia gravis
356.A 63-year-old woman accompanied by her husband is brought to the
ED by EMS with worsening right arm weakness that started 90 minutes ago
at the opera. Her husband states that she has a history of hypertension and
a long smoking history. She has no surgical history. The husband states that
his wife was fine when going to the opera. The patient’s BP is 215/118 mm Hg,
HR is 97 beats per minute, temperature is 99.3°F, and RR is 14 breaths per
minute. On examination, the patient is anxious, mildly aphasic, has 2/5
strength, and diminished sensation in the right upper extremity. An emergent
head CT scan is normal. It has been 2 hours since the onset of symptoms.
Which of the following is the most appropriate next step in management?
a. Administer labetalol.
b. Administer fibrinolytic therapy.
c. Administer aspirin prior to fibrinolytic therapy to reduce platelet aggregation.
d. Administer phenytoin prior to fibrinolytic therapy as seizure prophylaxis.
e. Administer mannitol to reduce intracranial pressure prior to fibrinolytic therapy.
378 Emergency Medicine