Differential Diagnosis for 37 YO with Complex Presentation

The patient's presentation with prolonged involuntary tremors, history of seronegative RA, hypersomnia, CRPS, functional neurologic disorder, pancreatitis, and diastasis pubis post-partum is complex and suggests a multifactorial etiology. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Psychogenic Non-Epileptic Seizures (PNES): Given the patient's history of functional neurologic disorder and the description of prolonged involuntary tremors with preserved awareness, PNES is a strong consideration. The psychological component, combined with the physical symptoms, aligns with the presentation of PNES.

• Other Likely Diagnoses

  • Seronegative Rheumatoid Arthritis (RA) Flare: Although the patient has seronegative RA, a flare could potentially explain some of the systemic symptoms, including possibly the tremors if related to inflammation or medication side effects.
  • Complex Regional Pain Syndrome (CRPS) Flare: CRPS can cause a variety of symptoms including tremors, especially if the condition is flaring. The patient's history of CRPS makes this a plausible explanation for some of the symptoms.
  • Hypersomnia Disorder: While primarily a sleep disorder, in the context of other systemic symptoms, it could contribute to or exacerbate the perception of tremors or be related to an underlying neurological condition.

• Do Not Miss Diagnoses

  • Thyroid Storm: Although less likely, thyroid storm can cause tremors, and given the potential for life-threatening outcomes if missed, it's crucial to rule out thyroid dysfunction.
  • Neuroleptic Malignant Syndrome (NMS): This rare but life-threatening condition can cause altered mental status, rigidity, and tremors. Given the patient's complex medical history, including the use of potential offending agents, NMS must be considered.
  • Status Epilepticus (Non-Convulsive): While the patient has preserved awareness, certain forms of status epilepticus can present with minimal or no convulsive activity, making this a critical diagnosis not to miss.

• Rare Diagnoses

  • Wilson's Disease: A genetic disorder that can cause neurological symptoms including tremors, psychiatric symptoms, and potentially pancreatitis. Although rare, it's an important consideration in young patients with a complex presentation.
  • Whipple's Disease: A rare, systemic bacterial infection that can cause a wide range of symptoms including neurological manifestations like tremors, and systemic symptoms like pancreatitis.
  • Stiff Person Syndrome: A rare neurological disorder characterized by progressive stiffness and rigidity of the muscles, which could potentially cause tremor-like symptoms.