Question

Neuromuscular Weakness Evaluation

Patient Profile

T.Y. is a 32-year-old male who presented to the emergency department with a 1-day history of gradually progressively increasing weakness of both the lower legs. This morning, he woke up and was unable to walk. Over the past few hours, he has noticed the weakness spreading to where it now involves both the upper limbs. Upon questioning, he states he has been training for a marathon and following a high carbohydrate diet. His past medical history is significant only for a recent emergency room visit for viral influenza 13 days ago. At that time, he had a high fever, malaise, vomiting, and generalized body pain. He was given intravenous fluids and sent home with instructions for symptomatic care.

Objective Data

Physical Examination

• Temperature 98.7° F, pulse 50, respirations 18, blood pressure 102/60

• Alert and oriented, cooperative

• Symmetric muscle weakness involving all four limbs with areflexia and hypotonia

• No evidence of diplopia or ptosis

• Normal bowel and bladder function

• No dysphagia

Diagnostic Studies

• 12-lead ECG: Sinus bradycardia with a rate of 50 beats/minute with ST segment depression

• Lumbar puncture: Cerebrospinal fluid (CSF) with normal protein and white blood cell (WBC)

• Labs pending: Complete blood count (CBC), complete metabolic panel, creatinine kinase-MB (CK-MB), troponin, antinuclear antibody (ANA), erythrocyte sedimentation rate (ESR), urinalysis with culture and sensitivity

Discussion Questions

1. T.Y. reports evolving muscle weakness that is confirmed by physical exam. Based on this finding, what is the priority nursing assessment for T.Y.?

2. The health care provider suspects T.Y. may have Guillain-Barre syndrome (GBS). What history and assessment data support this diagnosis?

3. Which cranial nerves would be important to check since T.Y. has suspected GBS? How would you perform this assessment?

4. Does the normal CSF exclude GBS?

5. What other diagnostic tests may be useful in determining a diagnosis for T.Y.?

Case Study Progress

T.Y.’s labs return and his serum potassium is 1.5 mEq. The provider now suspects that T.Y.’s symptoms are the result of hypokalemic periodic paralysis (HPP), triggered by his marathon training and diet, and orders oral potassium chloride (KCl) 0.2–0.4 mEq/kg (up to 30 mEq), repeated q30min depending on response of ECG, serum K+, muscle strength.

6. How are the neuromuscular manifestations associated with a critically low potassium level similar to those of GBS?

7. What assessment finding suggests that the potassium level is responsible for T.Y.’s symptoms?

Answer 1

●The priority nursing assessment for a patient with muscle weakness are

• Physical examination
  • Inspection :weakness, inability to walk
• Neurovascular assessment:
  • Pulse:50bpm
• Focused assessment
  • Musculoskeletal:areflexia,hypotonia,symmetric muscle weakness of all limbs

● The history of an recent infection of viral influenza and The assessment of weakness and inability to move both lower limbs followed by both upper limbs support the diagnosis of GBS

●The cranial nerve nine ,ten and occasionally or rarely twelfth nerve

• A simple swallowing test can be performed
• Gag reflex but toughing the inner part of the tongue
• Sense of taste

● CSF can remain normal for about first one to two weeks and raises after a couple of week from the time of weak ess.This feature exclude the GBS

●The diagnostic tests needed to diagnose the disease condition are

• Electromyography ,nerve conduction study to rule out GBS
• Serum electrolytes to ruke out the changes in these levels to cause muscle weakness

●The neuromuscular manifestation are

• Weakness of limbs ,even comple loss of motor function in the limbs happens in both hypokalemia and GNS
• Low blood pressure
• Bradycardia

7.The serum electrolyte level of potassium of 1.5mEq confirms the reason for symptoms. The others are changes in vital signs, musculoskeletal system,nerve reflexes.

Answer 2

1. Monitoring for a respiratory complication; Cardiac related to ST segment depression