Neuro Pt

[chbare]

Bell's palsy may be something to consider with isolated signs and symptoms only.

Take care,

chbare.

[AnthonyM83]

THen whats the question with the case?

Positive Rhomberg test in a 40yo female without any contraindications to fibrinolytics is pretty clear cut.

In my a previous job that test was used to gather build a case that the person was under the influence of drugs....

[OVeractiveBrain]

AS he said, no Hx of palsy, no exposure to infections that would present palsy, denies drug use

[ERDoc]

THen whats the question with the case? Positive Rhomberg test in a 40yo female without any contraindications to fibrinolytics is pretty clear cut.

That is a pretty brazen statement. We'll see if you are so nonchalant with such a dangerous medication once you have some clinical experience. It would take a little more than a positive Romberg for me to give lytics. Just because she does not have any contraindications does not mean that she has any indications. They are so many other things on the differential that need to be worked up first.

There are a couple of things that are unclear in this case. What exactly is meant by saying that the pt could not look up to the right? Was it with both eyes? Each eye will be using different cranial nerves to look up and to the right, so we cannot localize a lesion based on that. If the symptoms have been going on 2 weeks, by definition it is not a TIA. Which side of her face is numb and what is the distribution? What do you mean by she couldn't smile? A Romberg test does not test CN VIII, but is more of a test of cerebellar function. This definitely sounds neurologic, but there is more to think about than just a stroke.

[AnthonyM83]

AS he said, no Hx of palsy, no exposure to infections that would present palsy, denies drug use

How reliable are patients' assurances that there has been no drug use? Does it ever happen that drug use is unknown to the patient, in other words, they were given something by someone else without their knowledge? I'm just trying to offer alternatives because you said your statement very factually with finality.

[MAMed]

On the H-test pt could not look up with either eye. With the facial nerve, the pt could give a grimace and that is about it. As far as the Romberg test, my understanding is that the auditory nerve deals with hearing and balance and if you are on scene, such as this case, at a restaurant parking lot, there is too much background noise to test levels of hearing reliably. In that case a Romberg becomes the next best thing.

I cannot attest to drug use but I am assuming that the pt is telling the truth to see what the neuro problem might be.

The pt stated that her entire face is numb.

[sledogg1]

With her age and mental stability........did overdose come in mind.

SynthroidOverdosage & Contraindicationsfont sizeAAAOVERDOSE

The signs and symptoms of overdosage are those of hyperthyroidism (see PRECAUTIONS and ADVERSE REACTIONS). In addition, confusion and disorientation may occur. Cerebral embolism, shock, coma, and death have been reported. Seizures have occurred in a child ingesting 18 mg of levothyroxine. Symptoms may not necessarily be evident or may not appear until several days after ingestion of levothyroxine sodium.

Treatment of Overdosage

Levothyroxine sodium should be reduced in dose or temporarily discontinued if signs or symptoms of overdosage occur.

Acute Massive Overdosage – This may be a life-threatening emergency, therefore, symptomatic and supportive therapy should be instituted immediately. If not contraindicated (e.g., by seizures, coma, or loss of the gag reflex), the stomach should be emptied by emesis or gastric lavage to decrease gastrointestinal absorption. Activated charcoal or cholestyramine may also be used to decrease absorption. Central and peripheral increased sympathetic activity may be treated by administering β-receptor antagonists, e.g., propranolol, provided there are no medical contraindications to their use. Provide respiratory support as needed; control congestive heart failure and arrhythmia; control fever, hypoglycemia, and fluid loss as necessary. Large doses of antithyroid drugs (e.g., methimazole or propylthiouracil) followed in one to two hours by large doses of iodine may be given to inhibit synthesis and release of thyroid hormones. Glucocorticoids may be given to inhibit the conversion of T4 to T3. Plasmapheresis, charcoal hemoperfusion and exchange transfusion have been reserved for cases in which continued clinical deterioration occurs despite conventional therapy. Because T4 is highly protein bound, very little drug will be removed by dialysis.

CONTRAINDICATIONS

Levothyroxine is contraindicated in patients with untreated subclinical (suppressed serum TSH level with normal T3 and T4 levels) or overt thyrotoxicosis of any etiology and in patients with acute myocardial infarction. Levothyroxine is contraindicated in patients with uncorrected adrenal insufficiency since thyroid hormones may precipitate an acute adrenal crisis by increasing the metabolic clearance of glucocorticoids (see PRECAUTIONS). SYNTHROID is contraindicated in patients with hypersensitivity to any of the inactive ingredients in SYNTHROID tablets (See DESCRIPTION, Inactive Ingredients).