🧠 Mock Patient Script – Motor Paralysis

Case 1 – “I woke up and couldn’t move my right arm.”

Doorway Information

• Age / Gender: 71-year-old male
• Chief Complaint: Sudden right-sided weakness
• Vital Signs: T 36.8°C, HR 86, BP 172/96, RR 18, SpO₂ 98% RA

Structured History

Opening: “Yeah… I woke up and just couldn’t move my whole right side.”

Onset & Course: Sudden onset this morning. No trauma. Collapsed when trying to stand.

Associated Symptoms: Slurred speech, imbalance, no headache or vision changes.

Mood / Function / Appetite / Sleep: Scared, otherwise baseline normal.

Medical History: Hypertension (non-compliant), no diabetes or stroke history.

Social History: Smokes 1 pack/day × 40 yrs. Retired, lives alone. No alcohol/drugs.

Concerns: “Is this a stroke? Will I be paralyzed forever?”

Physical Examination

• Right facial droop (lower face)
• Right arm and leg weakness (3/5), pronator drift positive
• Increased reflexes on right
• NIHSS = 6

Differential Diagnosis

1. Ischemic stroke (MCA) – sudden focal deficit, HTN, smoking
2. Intracerebral hemorrhage – possible, but no headache or vomiting
3. Todd’s paralysis – no seizure activity

Clinical Reflection

The presentation was highly suggestive of MCA infarct. Vascular risk factors and neurological deficits supported this.

Clinical Pearls

• 🧠 “Time is brain” – act fast
• 🚬 HTN and smoking = big risk factors
• 🧪 Normal early CT doesn’t rule out stroke
• ✋ Facial + arm + speech = classic triad

Challenging Questions

Q: “Will I recover full movement?”
A: “We’ll do everything we can to help with recovery. Some patients improve a lot with rehab, while others may have lasting weakness. We’ll monitor closely and start therapy early.”

Q: “Can I get treatment to reverse this?”
A: “There are treatments like tPA that can help if given within a few hours. That’s why it’s so important we act fast. We’ll check your scans and labs right away.”

SOAP Note

S: 71M with sudden right hemiparesis and slurred speech upon waking. No headache, no seizure, no trauma.
O: T 36.8, HR 86, BP 172/96. Right-sided weakness 3/5, facial droop, increased reflexes.
A:
# Right-sided weakness
# Dysarthria
# Vascular risk (HTN, smoking)
ddx): MCA stroke, ICH, Todd's paralysis
→ MCA infarct likely. Urgent CT and neuro consult.
P:
- CT head
- Labs (CBC, BMP, PT/INR, glucose)
- Monitor vitals, neuro status
    

Case 2 – “I can’t move my eyes… and now I feel unsteady.”

Doorway Information

• Age / Gender: 29-year-old male
• Chief Complaint: Double vision and trouble walking
• Vital Signs: T 36.9°C, HR 78, BP 120/76, RR 16, SpO₂ 99% RA

Structured History

Opening: “I can’t move my eyes right. I feel dizzy and can’t walk straight.”

Onset & Course: Gradual over 2 days. Had flu-like illness 1 week ago (fever, sore throat).

Associated Symptoms: Ataxia, perioral numbness, diplopia. No limb weakness.

Medical History: Healthy, no meds.

Social History: Works in tech, social drinker, no drugs.

Concerns: “Could this be MS or a brain tumor?”

Physical Examination

• Ophthalmoplegia (lateral gaze limited)
• Ataxic gait
• Areflexia
• Normal strength and sensation

Differential Diagnosis

1. Miller-Fisher syndrome – classic triad + post-viral course
2. Cerebellar stroke/tumor – less likely, reflexes preserved
3. Myasthenia gravis – unlikely: no ptosis, reflexes normal

Clinical Reflection

The triad and post-infectious course pointed clearly to MFS. We’ll confirm with anti-GQ1b antibodies and LP.

Clinical Pearls

• 👁️ Ophthalmoplegia + ataxia + areflexia = MFS
• 🦠 Usually post-viral (e.g. flu, GI)
• 🧪 Anti-GQ1b positive in >90%

Challenging Questions

Q: “Is this a type of stroke?”
A: “It shares some features, but your symptoms developed gradually and your reflexes are absent, which points to a nerve-related cause. We’ll do scans and blood tests to make sure.”

Q: “Will I get better?”
A: “Most patients recover well with supportive care or immunotherapy. You may need close monitoring for breathing and walking, but recovery is very likely.”

SOAP Note

S: 29M with diplopia and ataxia post-viral illness. No weakness.
O: Ophthalmoplegia, ataxia, areflexia. Normal strength.
A:
# Ophthalmoplegia + ataxia + areflexia
# Post-viral course
→ Miller-Fisher likely. Rule out stroke.
P:
- MRI
- Anti-GQ1b Ab, LP
- Monitor FVC
- Neuro referral
    

Case 3 – “I must’ve slept funny… now I can’t extend my wrist.”

Doorway Information

• Age / Gender: 33-year-old male
• Chief Complaint: Wrist drop after sleeping
• Vital Signs: T 36.7°C, HR 72, BP 126/84, RR 16, SpO₂ 99% RA

Structured History

Opening: “I woke up and couldn’t lift my wrist.”

Onset & Course: After clubbing, fell asleep on couch with arm under woman’s body. Woke up with wrist drop.

Associated Symptoms: Dorsal hand numbness. No pain. Normal finger strength.

Medical/Social History: Healthy, no meds. IT job. Drinks socially. No drugs.

Concerns: “Did I damage my nerves forever?”

Physical Examination

• Wrist extensor weakness (wrist drop)
• Normal triceps reflex
• Sensory loss dorsum hand

Differential Diagnosis

1. Radial nerve palsy – compression + wrist drop
2. Cervical disc herniation – less likely: no neck pain
3. Peripheral neuropathy – no systemic cause

Clinical Reflection

Textbook case of compressive radial neuropathy after intoxication and poor posture.

Clinical Pearls

• 🛋️ “Saturday night palsy” = radial nerve compression
• 🍷 Alcohol + posture = risk
• 🧠 Triceps spared → distal lesion

Challenging Questions

Q: “Is this permanent?”
A: “It’s most likely temporary. The nerve got compressed, and it can take a few weeks to fully recover. We’ll monitor and may recommend physical therapy.”

Q: “Do I need an MRI?”
A: “Not right now. Based on your exam and history, this looks like a common nerve compression. If you don’t improve, we’ll reconsider imaging later.”

SOAP Note

S: 33M with wrist drop after sleeping on arm. No trauma.
O: Weak wrist extensors, sensory loss dorsum hand. Reflexes intact.
A:
# Radial nerve palsy (compression)
→ Saturday night palsy. Conservative management.
P:
- Reassure
- Wrist splint
- PT/OT
- Recheck in 2 weeks