went to er thinking i was having a stroke had mri and catscan found nothing what else could be wrong
Diagnosis
All Signs Pointed to a Stroke. Then the Tests Come Back Negative.
"Mom?" the middle-aged man asked. He recognized the voice, but the words were deadened and strange. I'll be right over, he said into the phone. The 15-minute drive from his modest Connecticut town to his mother's seemed to terminal forever. Had she had a stroke? She was 94, and though she'd e'er been healthy, at her age, annihilation could happen.
He burst into her tidy brick home to notice her sitting in the living room, waiting. Her eyes were vivid but scared, and her vocalization was just a whisper. He helped her to his car, then raced to the community hospital a couple of towns over.
The doctors in the emergency room were too worried about a stroke. Her left eyelid hung lower across her middle than her right. She was seeing double, she told them. And the left side of her mouth and tongue felt strangely heavy, making information technology difficult to speak. Initial blood tests came dorsum normal; so did the CT scan of her brain. It wasn't clear what was wrong with the patient, so she was transferred to nearby Yale New Haven Infirmary.
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Not Looking Your Age
Dr. Paul Sanmartin, a resident in the second year of his neurology training, met the patient early on the next morning. He'd already heard most her from the overnight resident: a 94-year-old woman with the sudden onset of a droopy eyelid, double vision and difficulty speaking, probably due to a stroke. Equally he entered the room, he realized he wasn't sure what 94 was supposed to look like, but this woman looked much younger. She did have a droopy left lid, just her eyes moved in what looked to him to be perfect alignment, and her speech, though quiet, was articulate.
The patient's story was besides different from what he expected. She had macular degeneration and had been getting shots in her left eye for more than a decade. Her last injection was about two weeks earlier, and she'd had double vision and the droopy eyelid on and off ever since.
Did she have double vision now, the young md asked? She glanced around the room. Not just then, just it would come back, she was sure of it. Other than the macular degeneration, the woman had only loftier blood pressure level, for which she faithfully took a pill each day. She lived alone, and until all this happened, drove herself to all her appointments and volunteered at a local school for the disabled.
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Unrevealing Tests
The young md held upwardly a finger, instructing the woman to follow it with her eyes as he traced a large box in front of her confront. Her eyes moved normally. He asked her to stick her arms out "like chicken wings," and he pushed downwardly on them repeatedly, testing her strength. She seemed a lilliputian weaker on the 2d or 3rd fourth dimension. She felt weak all over, she told him. Not equally strong as she used to be.
Sanmartin thought that the patient probably had a stroke. Less likely, simply possible, she could have a small mass or tumor. Myasthenia gravis (MG), an autoimmune disease that causes intermittent musculus weakness, was likewise possible but less likely at her age. She definitely needed an Yard.R.I. and too a scan called an K.R.A. to look at how the blood flowed through her brain. And she needed a swallowing study because she said she was choking on her food at home. Whatever fabricated it difficult to talk could arrive hard to consume too.
The Grand.R.A. was normal; so was the Thousand.R.I. There was no stroke, no brain tumor. All the blood tests were completely normal. By Day four in the hospital, the plan was to send her habitation. She would demand a follow-up appointment with her eye doctor because the lid was still droopy, and with an ear, nose and pharynx doctor because she complained of difficulty swallowing, fifty-fifty though she had passed a swallowing test just that forenoon. He wasn't certain what she had but figured that they had ruled out the possibilities that might kill her.
That night at the hospital, though, she proved them wrong; she high-strung while eating dinner. She wasn't going anywhere.
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Circling Back
When Sanmartin presented the patient to Dr. Richard Nowak, the neurologist who took over the team as the attending doc, information technology still wasn't articulate what was incorrect with her. But even earlier seeing the elderly woman, Nowak told the resident, he already had a diagnosis in listen — he did think she had myasthenia gravis. In this rare autoimmune disorder, the trunk's defense system mistakenly attacks the connections between the nerve fibers and the muscles they command, causing the muscles to tire out rapidly.
Sanmartin was surprised. He'd discussed this at length with the last attending neurologist, who was only every bit sure it wasn't MG. That medico argued that although myasthenia frequently causes weakness in the muscles of the eyes and mouth — not unlike what this woman had — that weakness usually comes and goes. But this woman's symptoms were consistently present. Besides, the resident added, at 94, wasn't she as well quondam for that?
Age was not a factor, Nowak said. As the manager of Yale's myasthenia clinic, he recently diagnosed the disease in a 98-twelvemonth-old man. And although men tend to become the disorder later than women — men were more likely to get it in their 60s and women in their 20s and 30s — age lone can't be used to rule it out. In the concurrently, the squad should send off the claret tests for MG because information technology commonly took a week or more than for the results to come back.
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A Tired Vocalism
Sanmartin watched the more experienced doc examine the woman. Nowak couldn't find whatsoever prove of double vision. And the patient passed all the tests he did to try to tire out the muscles of the eyes and shoulders. Then Nowak asked the patient to count to 50 out loud. At 29, her voice changed. Information technology got quieter and a little raspy. By the time she got to 50, it was barely a whisper, as the muscles she used to speak gave out. She probably did have MG, Nowak told his resident. Still, it wasn't proof enough for him to care for her.
Each morning, when Nowak came to run across her, her exam was the same — suggestive just not definitive. One day he wasn't able to run across the adult female until tardily afternoon. She was alert and engaged every bit always, but her words were slurred and nigh inaudible. Muscle weakening belatedly in the day is a classic symptom of MG. The test results hadn't come dorsum yet and probably wouldn't for several more than days, so Nowak decided to try a unlike exam. He would commencement her on a low dose of Mestinon, the drug used to reduce the muscle weakening of MG. If she responded, the diagnosis would be confirmed.
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Successful Treatment
Sanmartin had the day off when the patient started on the medicine. When he returned the next morning, he hurried to see her. She was awake and smiled as he walked in. She greeted him, and he immediately noticed the modify in her vocalization. The nasal quality he heard before was gone. She spoke as if with a different phonation. She could even drink water. Sparse liquids like that are the most challenging to consume.
When the test results finally came back positive for MG, no 1 was surprised. They started her on a second medication. The promise was that the dual approach of Mestinon for relief of the symptoms and the 2nd drug to aid protect her from her wayward immune system would prevent hereafter attacks.
And information technology did — at least for a while. But a couple of months later, the woman had a life-threatening outburst of her disease, an episode of weakness that left her incapable of animate on her own. She was on a ventilator for nearly a calendar week. And strangely, like her first episode of weakness, this terrible crisis came right after she got the injection to care for her macular degeneration. Was this some unusual reaction to a medicine she'd been taking for years? According to Nowak, no link between the medicine she took and MG has been reported. But she's unwilling to take that risk — or the middle medication — again. And if her vision worsens, she told me with the cheerful decision of a survivor, she yet has her other center.
Source: https://www.nytimes.com/2017/09/26/magazine/all-signs-pointed-to-a-stroke-then-the-tests-come-back-negative.html
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