A 23-Year-Old Woman With Emesis and Generalized Weakness

Greg P. Hansen, DO; Christo T. Philip, MD; Larissa I. Velez, MD


September 14, 2017

Physical Examination and Workup

On physical examination, the patient's oral temperature is 99°F. Her pulse is regular, with a rate of 75 beats/min. Her blood pressure is 112/60 mm Hg, and she has a respiratory rate of 18 breaths/min with an oxygen saturation of 98% while breathing room air. She appears uncomfortable and generally fatigued, but is alert and oriented.

The patient's extraocular muscles are intact, with no nystagmus. Her pupils are symmetric and equally reactive to light, and the optic discs appear normal. Her mucous membranes are moist, and the remainder of the head, ear, nose, and throat examination is normal. Her lungs are clear to auscultation, and the patient exhibits normal respiratory effort. The heart rhythm is regular, without murmurs, rubs, or gallops. Her abdomen is nontender, without masses, and there is no appreciable costovertebral angle tenderness. The extremities are without edema, and the radial pulses are strong bilaterally. The skin is clear, without rash, petechiae, or ecchymoses.

Cranial nerves II-XII are normal and symmetric. Otherwise, the neurologic examination reveals 2/5 strength throughout both upper and lower extremities, with 1/3 patellar, triceps, and Achilles reflexes bilaterally. The patient has negative Babinski and Hoffmann signs. Finger-to-nose coordination and gait could not be assessed as a result of her weakness.

An ECG (Figure 1), urine analysis, urine pregnancy test, and basic metabolic panel are completed soon after arrival.

Figure 1.

The pregnancy test result is positive. She has a serum glucose concentration of 97 mg/dL and a hemoglobin level of 13.4 g/dL. As a result of a low bicarbonate finding on the metabolic panel, arterial blood gas measurement is subsequently performed; this shows a pH of 7.25, a partial pressure of carbon dioxide of 22 mm Hg, a partial pressure of oxygen of 100 mm Hg, and a bicarbonate level of 9 mEq/L. The urine analysis shows a pH of 7, with moderate blood, negative nitrates, and small leukocytes.

Renal ultrasound is completed before admission (Figure 2).

Figure 2.


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