Illness Script for Myasthenia Gravis

Keep/Refer
Decision: Refer

REFER

Case Description:

A 27-year-old, Caucasian woman is referred to physical therapy by her PCP for general
weakness in her both of her arms and feeling that she fatigues easily. Upon examination, she
reveals that she has been like this for around two months. The patient does not complain of any
localized pain with symptoms. She does note that the activities she used to complete within her
day, she can’t perform anymore due to her fatigue after the first few hours of her day. She
mentions that these symptoms are getting slightly worse, and she is starting to feel them within
her legs recently, but not as dramatic as the arms. She was just promoted to manager of a
warehouse four months ago and notices that this is starting to interfere with her responsibilities at
work.

After a screen for red flags, you are informed that she also has been having diplopia (noted by
the blue oval) and trouble swallowing (noted by a green square) for the past few months. She
contributes the diplopia to her new glasses prescription that she thought was wrong and her
trouble swallowing due to allergy season. She has tried cough drops and other allergy medicine,
which usually works; however, those did not seem to help for the first time in her life. She
believes that since she has stopped working out after being promoted to the manager position,
this is the cause of her weakness in the arms and legs (noted with red stars). Upon the patient
walking from the waiting room to the exam room, you notice that she has an “unsteady gait.”

Past Medical History: No major surgeries or injuries to any extremity have been noted. She
usually has seasonal allergies and takes a 10 mg Zyrtec tablet each day.

Group Members: Savannah Walker, Isaac Weir, Ian Hart, Ally Malcolm, & Tommy LaViolette 1
Physical Features:

After viewing the young woman, you report that she seems agitated and anxious about her
symptoms. She seems to have low muscle tone in her extremities compared to what you would
expect. You notice she is showing ptosis in both of her eyes, and she seems to be fatigued by her
demeanor and gait when walking.

Physical Therapy Findings:

Upon physical therapy examination, you note that there is no pain with palpation or movement.
You note that there is weakness upon testing the upper extremities and lower extremities, but no
signs of sensory or neurological impairment. You note that the patient has an unsteady gait when
walking. You note that the patient is experiencing double vision and trouble swallowing. You are
not able to provoke pain with any special tests.

Problems List:

Weakness and fatigue in upper extremities that has started to show in the lower extremities as
well

Diplopia

Trouble swallowing

Unsteady gait pattern

Differential Diagnosis (What is this similar to? What should be ruled out?)

Lambert-Eaton syndrome is an autoimmune presynaptic disorder of the neuromuscular junction

that can cause symptoms close to MG, mainly causing muscle weakness. Lambert-Eaton is
associated with a neoplasm, which is a small cell carcinoma of the lung that triggers the
autoimmune response so you may to want to get a biopsy or CT/PET/MRI scan to rule this out.

Rule out drug induced myasthenia, hyperthyroidism, botulism, intracranial mass lesions, and
progressive disorders of the eye, which are all conditions that can cause weakness of the cranial
or somatic muscles.
Interesting link: Larson ST, Wilbur J. Muscle Weakness in Adults: Evaluation and Differential Diagnosis. Am Fam Physician.
2020;101(2):95-108. https://pubmed.ncbi.nlm.nih.gov/31939642/

Group Members: Savannah Walker, Isaac Weir, Ian Hart, Ally Malcolm, & Tommy LaViolette 2