1.10 Weakness
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agk's Library of Common Simple Emergencies


Presentation
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An older patient comes to the emergency 
department or is brought by family, complaining 
of "weakness," or an inability to carry on his 
usual activities or care for himself.

What to do:
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- Work at obtaining as much history as 
   possible. Speak to available family members 
   or friends, as well as the patient, and ask 
   for details. Is the patient weak before 
   certain activities? (suggestive of depress- 
   ion). Is the weakness located in the limb 
   girdles (suggestive of polymyalgia 
   rheumatica or myopathy). Is the weakness 
   mostly in the distal muscles? (neuropathy). 
   Is the weakness brought out by repetitive 
   actions? (myasthenia gravis). Is the 
   weakness unilateral with slurring of speech 
   or confusion? (cerebrovascular accident).
- Obtain a thorough medical history and 
   physical examination, including a review of 
   systems (headaches, weight loss, cold 
   intolerance, appetite, bowel habits), 
   strength of all muscle groups (graded on a 
   scale of 1-5), deep tendon reflexes, and 
   neurological status. Order a head CT is 
   there is an unexplained change in mental 
   status or if there are abnormal neurologic 
   findings.
- Obtain a spectrum of laboratory tests which 
   will be available within the next 2 hours, 
   including pulse oximetry, chest x-ray, 
   electrocardiogram, urinalysis, blood counts, 
   glucose, BUN, and electrolytes which may 
   disclose hypoxia, anemia, infection, 
   diabetes, uremia, polymyalgia rheumatica, 
   hyponatremia and hypokalemia, all of which 
   are common causes of "weakness." (Testing 
   for serum phosphate and calcium are also 
   valuable, if available stat.)
- If no etiology for weakness can be found, 
   probe the patient, family, and friends once 
   again for any hidden agenda, and if none is 
   found, reassure them about all the serious 
   illnesses which have been ruled out. At this 
   time, discharge the patient and make 
   arrangements for definite followup.

What not to do:
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- Do not order any laboratory tests the results 
   of which you will not see. Your best strat- 
   egy is to stick to tests which will return 
   while the patient is in the emergency 
   department, and defer any long investiga- 
   tions to the followup physician. Laboratory 
   results which are never seen or acted upon 
   are worse than none at all.
- Do not insist upon making the diagnosis in 
   the emergency department in every case. In 
   this clinical situation, your role in the ED 
   is to rule out acutely life-threatening 
   conditions, and then make arrangements for 
   further evaluations elsewhere.

Discussion
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Approach the patient with "weakness" with an 
open mind and be prepared to take some time 
with the evaluation. Demonstrable localized 
weakness usually points to a specific 
neuromuscular etiology, while generalized 
weakness is the presenting complaint for a 
multitude of ills. In young patients, weakness 
may be a sign of psychological depression while 
in older patients, in addition to depression, 
it may be the first sign of a subdural 
hematoma, pneumonia, urinary tract infection, 
diabetes, dehydration, malnutrition, heart 
failure, or cancer. 

It is important to exclude the Guillain-Barre 
syndrome as one of the critical, life-threat- 
ening etiologies to weakness. The pattern is 
not always an ascending paralysis or weakness, 
but usually does depress deep tendon reflexes. 
Botulism is another condition that must be 
excluded by history or observation. Patients 
who are suffering from these sorts of 
neuro-muscular weakness get into danger when 
they can't breathe. Pulmonary function studies 
like pulse oximetry, capnography, blood gases, 
peak flow or vital capacity can be helpful in 
selecting patients who might be close to severe 
respiratory embarrassment.

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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