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Patient Information:
- Name: [Redacted]
- Age: 22 years old
- Gender: Female
- Date of Examination: [Date]
Clinical Findings: The patient presented with progressive stiffness and rigidity, predominantly affecting the axial muscles, including the trunk and proximal extremities. She reported intermittent spasms and heightened sensitivity to tactile stimuli.
Electromyography (EMG) Report:
- Paraspinal Muscles:
- Resting EMG: Abnormal
- Findings: Continuous motor unit activity observed during rest, with high-frequency bursts of action potentials, characteristic of continuous motor unit activity (CMUA) seen in Stiff Person Syndrome (SPS).
- Axial Muscles (Trunk and Proximal Extremities):
- Resting EMG: Abnormal
- Findings: Persistent background activity with superimposed bursts of motor unit action potentials, suggestive of involuntary muscle contractions and co-contractions, consistent with the "stiffening" phenomenon seen in SPS.
- Flexor and Extensor Muscles of Upper and Lower Limbs:
- Resting EMG: Abnormal
- Findings: Spontaneous motor unit activity observed during rest, including fibrillation potentials and positive sharp waves, indicative of ongoing denervation and reinnervation processes commonly seen in SPS.
Impression: The electromyography findings are consistent with Stiff Person Syndrome, characterized by continuous motor unit activity at rest and heightened muscle rigidity and spasms upon stimulation. Further evaluation, including serological testing for anti-GAD antibodies and neuroimaging studies, may be warranted to confirm the diagnosis and guide management.
Recommendations:
- Referral to a neurologist for comprehensive evaluation and initiation of pharmacotherapy, including benzodiazepines, baclofen, or intravenous immunoglobulin (IVIG).
- Consideration of physical therapy for symptom management and maintenance of mobility.
- Regular follow-up assessments to monitor disease progression and treatment response
