A 39-year-old woman comes to the emergency department with sudden right leg weakness. The patient's medical history is significant for gastroesophageal reflux disease, which provokes occasional heartburn after meals despite medication therapy. She does not use tobacco, alcohol, or illicit drugs. The patient's husband of 20 years recently died suddenly in a car accident. Blood pressure is 120/70 mm Hg, pulse is 82/min, and respirations are 12/min. She has mild epigastric discomfort on palpation, but the rest of the abdominal examination is within normal limits. Neurological examination shows normal muscle tone, normal deep-tendon reflexes, and no Babinski sign in the extremities. The patient cannot lift her right leg off the bed while supine and is very worried that something is wrong. She is able to stand without assistance from a sitting position and her gait is without abnormalities. Which of the following is the most likely diagnosis?

Question

A 39-year-old woman comes to the emergency department with sudden right leg weakness.  The patient's medical history is significant for gastroesophageal reflux disease, which provokes occasional heartburn after meals despite medication therapy.  She does not use tobacco, alcohol, or illicit drugs.  The patient's husband of 20 years recently died suddenly in a car accident.  Blood pressure is 120/70 mm Hg, pulse is 82/min, and respirations are 12/min.  She has mild epigastric discomfort on palpation, but the rest of the abdominal examination is within normal limits.  Neurological examination shows normal muscle tone, normal deep-tendon reflexes, and no Babinski sign in the extremities.  The patient cannot lift her right leg off the bed while supine and is very worried that something is wrong.  She is able to stand without assistance from a sitting position and her gait is without abnormalities.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d75e_e57f_bc81_2b1721bf6865_MD0003_00 This patient's sudden onset of neurological symptoms with examination findings that are inconsistent with the pathophysiology of known neurological disease suggests a diagnosis of conversion disorder (also known as functional neurological symptom disorder). Common presentations include unexplained weakness/paralysis, nonepileptic seizures, aphonia, blindness, and paresthesia. Despite their psychological origin, the symptoms are not feigned or intentionally produced. Contrary to popular belief, patients may be quite distressed by their symptoms. An indifferent attitude toward severe symptoms (ie, la belle indifférence) occurs with equal frequency in both conversion and true neurological disorders and therefore is not a reliable indicator of conversion disorder. Common triggers for conversion disorder include relationship conflicts or other stressors with an intense emotional component. First-line treatment includes education about the disorder, validation for the distress it causes, and support for patients and family members. If patients do not respond to education, cognitive-behavioral therapy is a second-line option. (Choice B) Factitious disorder is the intentional production of physical or psychological symptoms with the goal of assuming a sick role; there is no evidence that this patient is motivated to assume a sick role. (Choice C) Illness anxiety disorder (previously known as hypochondriasis) is characterized by excessive worry over having or developing a serious illness while having very mild or nonexistent somatic symptoms. Illness anxiety disorder does not present with the unexplained neurological symptoms found in conversion disorder. (Choice D) Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives (eg, unemployment benefits, money, narcotics). External incentives are notably absent in this patient. (Choice E) Multiple sclerosis presents with neurological symptoms that correspond with demyelinating disease in the CNS. This patient's presentation is inconsistent with known neurological pathophysiology and therefore would be incompatible with a diagnosis of multiple sclerosis. (Choice F) Somatic symptom disorder involves excessive anxiety about ≥1 physical symptom(s) lasting for ≥6 months and can occur in patients whose symptoms are explained by recognized diseases. In contrast, this patient's symptoms and related anxiety are acute, seemingly proportional to the severity of impairment, and do not meet duration criteria. Educational objective: Conversion disorder is characterized by the sudden onset of neurological symptoms with clinical findings that are incompatible with recognized neurological conditions. Conversion disorder is often precipitated by stress. References: Assessment of patients with functional neurologic disorders. (http://www.ncbi.nlm.nih.gov/pubmed/27719837) Conversion disorder-mind versus body: a review. (http://www.ncbi.nlm.nih.gov/pubmed/26155375) Functional neurologic disorders. (http://www.ncbi.nlm.nih.gov/pubmed/26039857)

A 39-Year-Old Woman Comes to the Emergency Department with Sudden