History of Present Illness:
A woman in her mid 70’s with a history of HL presents to the ER with 72 hours of slurred speech which is gradually getting progressively worse. In addition, she can’t keep food or drink in her mouth. She fell 6 weeks ago, seen at OH and had a hip replacement but did not hit her head. She denies any arm or leg weakness, sore throat, fever, generalized weakness or other complaints.
Vital Signs & Physical Exam:
Vital signs are all normal. There is dysarthria but not aphasia; there is bilateral orbicularis oris weakness, otherwise no CN II-XII deficits. Gross motor strength equal in all four extremities.
Difficulty with rapid alternating hand movement bilaterally; heel to shin movement intact bilaterally.
Initial Diagnostic Testing:
- CBC, BMP and trop all normal
- UA 10-20 WBC
- CT
What is the diagnosis?
- A) SDH
- B) CVA
- C) UTI
- D) None of the above
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What is the most likely diagnosis?
- A) SDH
- B) CVA
- C) UTI
- D) None of the above – CORRECT – Tensilon test was positive as was acetylcholinesterase antibody test.
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CASE CONCLUSION: Started on Mestinon and was doing better on call back a few days later
CASE LESSONS: Slurred speech w/o generalized weakness? Consider bulbar palsy especially if also trouble chewing, swallowing or keeping food in mouth.