Weakness
Age: years old
Gender:
HISTORY:
Presents with a - history of generalized weakness
Onset was , started
Severity is and impact on daily activities is
Pattern
Associated symptoms: *Try using right-click for negatives*
, , , ,
, over ,
, up to °, over
, , , ,
Contributing factors:
no history of: , ,
no use of: , , , ,
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , , , bowel sounds , ,
Skin: on
Extremities: , , cap refill sec, pulses , ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought , , judgment
ASSESSMENT:
DDx: deconditioning, electrolyte imbalance, anemia, thyroid disease, diabetes mellitus, adrenal insufficiency, neuromuscular disorders (e.g., myasthenia gravis, muscular dystrophy), COPD, heart failure, chronic kidney disease, liver disease, infection, rheumatologic conditions, malignancy, medication side effect, vitamin D deficiency, vitamin B12 deficiency, neurological conditions (e.g., multiple sclerosis, Parkinson's disease), depression, chronic fatigue syndrome, fibromyalgia, sleep apnea, long Covid
PLAN:
Investigations:
- Blood work: , , , , , , , , , , , , , , , , , , , , ,
- Urinalysis
- ECG
- Chest X-ray
- CT scan of the chest/abdomen/pelvis
- MRI of the brain and spinal cord
- EMG and nerve conduction studies
Treatments:
-
-
- Occupational therapy
- Dietary counseling
Further care:
- Follow-up in
- Return if weakness worsens or if new symptoms develop such as difficulty breathing, swallowing difficulties, or profound fatigue
HISTORY: Associated symptoms: EXAM: ASSESSMENT: PLAN: