A 27 year-old woman comes to your ED with a year-long history of weakness, dizziness, and fatigue. She lost her job last year and ascribes her symptoms to this. She denies SI, HI, or perceptual disturbances. Her vital signs are normal, and her general and gross neurologic exams are unremarkable. Anticipating a quick discharge after some counseling and connection with resources, you take her hand and notice bilateral thenar wasting.
On further investigation, she has easy fatigue, becomes short of breath very easily, and finds her eyes “droopy” often. What concerns her most is that when she accidentally brushes up or hits against a piece of furniture, her thigh tenses up immediately, and “it takes awhile for it to relax again”.
During the conversation, her speech changes, as if her tongue were injured – “it’s my tongue again – it just stops working sometimes”.
You see this picture initially.
This resolves after a minute, and she feels normal again.
What is the best management approach for this woman?
A. Call for a psychiatric consult for likely malingering
B. Discharge home, arrange follow-up with a primary medical doctor
C. Draw blood to assess possible drug ingestion
D. Start IV fluids, calcium gluconate for likely black widow spider envenomation
E. Arrange for neurology consult
On further investigation, she has easy fatigue, becomes short of breath very easily, and finds her eyes “droopy” often. What concerns her most is that when she accidentally brushes up or hits against a piece of furniture, her thigh tenses up immediately, and “it takes awhile for it to relax again”.
During the conversation, her speech changes, as if her tongue were injured – “it’s my tongue again – it just stops working sometimes”.
You see this picture initially.
This resolves after a minute, and she feels normal again.
What is the best management approach for this woman?
A. Call for a psychiatric consult for likely malingering
B. Discharge home, arrange follow-up with a primary medical doctor
C. Draw blood to assess possible drug ingestion
D. Start IV fluids, calcium gluconate for likely black widow spider envenomation
E. Arrange for neurology consult
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