Paul Zee
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Paul Zee is a 28 year old man who has presented to clinic with weakness in his left arm. He noticed the weakness when he was playing golf. He has recently been let go from work as an electrician as he was unable to focus on wiring for long periods of time. He is otherwise fit and well.
Please identify the key issues in Paul’s history and formulate a differential diagnosis for his presentation, eliciting his concerns. Medications:
Cetirizine OD Diprobase PRN
You are 28 year old Paul Zee. You trained as an electrician for years, and absolutely loved your work. However, you have been recently fired after months of poor performance and mishaps. This has become really frustrating. To make matters worse, you’ve noticed some weakness in your arm whilst playing golf recently. This was the last straw, as you’re really proud of your golf swing!
PC: 1 month history of arm weakness. 3 month history of poor concentration.
HPC: You first noticed you were unable to concentrate three month ago, and it became gradually worse after this. At first, after about 10 minutes, your vision became blurry and you had to look away and take a break. However, now this has shortened to under 5 minutes, and you get pains in your eyes when you try to concentrate from time to time. This pain and blurred vision is worse in your right eye, strangely. You don’t have any problems with any of your other senses, but have had one or two dizzy episodes recently. You haven’t had any numbness or tingling in any of your arms or legs. You can’t remember any hot or cold episodes either.
If comfortable speaking about this, you might want to mention that things haven’t been going too well at home recently. You feel that you have let your partner down financially by losing your job, and are embarrassed to say that you have had some ‘difficulties in the bedroom’ recently. Specifically you have found it difficult to maintain an erection. This is troubling you, but you put it down to stress. All of this is placing a great burden on your relationship.
ICE: You think that you might have strained or pulled a muscle recently, as you have been playing a lot more golf with your time off. You’re quite relaxed about your weakness, but are generally a bit more concerned regarding your employment situation. You took pride in your work, and are worried further lack of concentration will mean that you won’t be able to hold down employment in the future.
PMH: Nothing to note
DH: Cetirizine for hayfever, diprobase for very mild eczema No known drug allergies
FH: No family history to note
SH: You live with your partner, who is a teacher. You do not smoke, and drink a few pints of lager with your friends on a Saturday when watching football. You haven’t recently as you’ve not really been interested in going out and seeing friends too much.
Please observe the student taking the history and performing the examination. Student should choose an examination they feel is appropriate, as long as they can reasonably justify it please allow it. We would recommend the examination should include a neurological examination of the upper limb, specifically motor. However, allow variations, including eye exam. Please list your differential diagnosis for this patient? My differential diagnosis would include a neurological cause, more specifically: Multiple sclerosis, presenting with Optic Neuritis. However, I would want to consider Motor Neuron Disease or Bell’s Palsy as a potential diagnosis. This could also be an endocrine cause, including thyroid disease, specifically thyrotoxicosis.
Suggestions for further discussion questions: - How would you investigate this patient in the acute setting? - How would you manage this patient initially? - How would this patient be managed in the long term? - What health care professionals would be involved in this patient’s care? - What patterns of progression can MS take? - What is the eye pain that this patient experiencing? - How does MS differ from Motor Neuron Disease? - What is Bell’s Palsy? How is it managed?
