Differential Diagnosis

The patient's presentation of eyes rolling back into her head and arms shaking could be indicative of several conditions. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Seizure (True Sz): This is the most likely diagnosis given the patient's symptoms. The eyes rolling back into her head (possibly indicating a loss of consciousness or altered mental status) and arms shaking are classic signs of a seizure. Seizures can manifest in various ways, including generalized tonic-clonic seizures which could cause the described symptoms.

• Other Likely Diagnoses

  • Cardiogenic Shock: Although less likely than a seizure given the specific symptoms, cardiogenic shock could potentially cause altered mental status (including the eyes rolling back) due to inadequate cerebral perfusion. However, the arms shaking would more typically be associated with seizure activity rather than the direct effects of cardiogenic shock.
  • Hypoglycemia: Low blood sugar can cause a range of neurological symptoms, including confusion, loss of consciousness, and tremors or shaking. It's a condition that needs to be considered, especially if the patient has a history of diabetes or other metabolic disorders.

• Do Not Miss Diagnoses

  • Status Epilepticus: A life-threatening condition where the patient has a seizure lasting more than 5 minutes or two or more seizures between which the patient doesn't return to baseline. Given the patient's symptoms, if this is indeed a seizure, status epilepticus is a critical diagnosis not to miss due to its high morbidity and mortality.
  • Stroke or Transient Ischemic Attack (TIA): While less likely given the specific symptoms of eyes rolling back and arms shaking, stroke or TIA could present with a wide range of neurological deficits, including altered mental status and focal neurological signs. Missing a stroke could have devastating consequences.
  • Meningitis or Encephalitis: Infections of the brain or meninges can cause seizures, altered mental status, and a variety of other neurological symptoms. These conditions are medical emergencies and require prompt diagnosis and treatment.

• Rare Diagnoses

  • Psychogenic Non-Epileptic Seizures (PNES): These are events that resemble epileptic seizures but are not caused by abnormal electrical activity in the brain. They are psychological in origin and can be very difficult to distinguish from true seizures without video EEG monitoring.
  • Hashimoto's Encephalopathy: A rare condition associated with Hashimoto's thyroiditis, characterized by altered mental status, seizures, and tremors, among other symptoms. It's a diagnosis to consider in patients with known thyroid disease or autoimmune disorders.
  • Neuroleptic Malignant Syndrome (NMS): A life-threatening neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic medication. Symptoms can include altered mental status, muscle rigidity, and tremors. Given the potential for severe outcomes, it's crucial to consider NMS in patients taking these medications.