Weakness

Question 1

Sequence of events

Answer 1

Open question

Timeline- when, progression etc.

Question 2

Symptom analysis

Answer 2

SOCRATES

Site- specific location or general, one side or both 
Onset- suddenly or gradually, what were you doing at the time 
Character- always there, or go away
Radiation- weakness anywhere else 
Associated features- systems review
Timing- happened before?
Exacerbating or relieving factors 
Severity- how bad

Question 3

Systems review

Answer 3

NS- numbness or tingling, changes in vision, hearing, taste, smell, reduction in muscle bulk, balance, speech, headaches, seizures, blackouts

Paine elsewhere, incontinence (bowels and urine)

Constitutional- FWARJNLCBBD

Question 4

Patients perspective

Answer 4

Feelings and impact on life

ICE

Question 5

Background

Answer 5

PMH
DH
FH- ask about muscle and movement disorders
SH

Question 6

Muscular dystrophy

Answer 6

Onset during childhood
Painless gradual weakness predominantly affecting proximal limb muscles
Difficulty standing up and walking

Question 7

Polymyositis/Dermatomyositis

Answer 7

Slow onset proximal muscle weakness and myalgia- difficulty standing up and walking
Fever, skin changes, Raynaud’s phenomena, interstitial lung disease

Question 8

Muscle wasting from disuse

Answer 8

Bedbound for a long time

Limb casts

Question 9

Myasthenia gravis

Answer 9

Autoimmune disorder- muscles become weak after use
Affects face, eye movements, eyelid mostly
Proximal myopathy with symptoms worse at the end of the day
Thymoma often present

Question 10

Lambert Eaton myasthenic syndrome

Answer 10

Paraneoplastic
Unlike MG, spares the eyes
Weakness improves on repeated use of the muscle
Autonomic dysfunction

Question 11

Peripheral nerve disorders

Answer 11

Peripheral neuropathy
Mononeuropathy
Mononeuritis multiplex

Question 12

Spinal cord diseases

Answer 12

Radiculopathy
Cervical spondylosis
Syringomelia
Spinal stenosis

Question 13

CNS disease

Answer 13

MS
Stroke
Tumour/abscess (SOL)

Question 14

Motor neuron disease

Answer 14

Loss of upper and lower motor neurones 
Limb weakness (dropping objects, heavy legs), speech problems, dysphagia, dyspnoea, no sensory or sphincter loss
Often 40+
Difficulties with AODL
Rule out other causes first

Question 15

Investigations

Answer 15

Full neurological examination (upper,lower, cranial nerves, cerebellum)
Observations.
Bloods- FBC UE CK creatinine kinase magnesium phosphate vitamin B12 and folate
Nerve conduction studies
MRI head and spinal cord (depends on suspected cause)