Differential Diagnosis for 19 YOF with Twitching and Radiating Pain

• Single Most Likely Diagnosis
  • Musculoskeletal issue or nerve entrapment: Given the patient's history of open heart surgery and the description of pain radiating down the arm, a musculoskeletal issue such as a nerve entrapment (e.g., thoracic outlet syndrome) or a complication from the surgery could be the cause of the symptoms. The twitching could be related to nerve irritation.
• Other Likely Diagnoses
  • Seizure disorder: Despite the patient being prescribed gabapentin, which is often used for seizure control, the worsening twitching and new onset of slurred speech (as reported by the mother) could suggest a seizure disorder or inadequate control of seizures.
  • Neuropathic pain: The patient's complaint of pain and the prescription of gabapentin suggest neuropathic pain could be a significant component of the patient's condition.
  • Complications from open heart surgery: Given the recent history of open heart surgery, complications such as a thoracic duct injury or other surgical complications could be contributing to the patient's symptoms.
• Do Not Miss Diagnoses
  • Stroke or transient ischemic attack (TIA): Although less likely in a young patient, stroke or TIA must be considered, especially with symptoms like slurred speech and facial weakness (even if not currently noted). The history of open heart surgery increases the risk of thromboembolic events.
  • Intracranial hemorrhage or other CNS emergencies: These conditions are life-threatening and require immediate diagnosis and treatment. The patient's symptoms of worsening twitching, slurred speech, and new pain could potentially indicate a CNS emergency.
• Rare Diagnoses
  • Multiple sclerosis: This autoimmune disease can cause a wide range of neurological symptoms, including twitching, pain, and speech difficulties. However, it is less common and would typically present with more disseminated symptoms in time and space.
  • Mitochondrial myopathies: Given the patient's history of open heart surgery and current symptoms, a mitochondrial myopathy could be considered, especially if there's a family history or other systemic symptoms. However, this would be a rare and less likely diagnosis without further supporting evidence.