History

Chief complaint: “When I woke up yesterday my legs felt so stiff, I could barely walk. My hands shake every time I try to paint. I feel uncoordinated, exhausted,  and just not like myself lately.”

History of present illness: Ms. N.S. is a 29 yo white female, who was referred to the neurology clinic by her PCP after complaining of frequent episodes of weakness, fatigue, and a tingling sensation in different areas of her body. She states she first started noticing symptoms about 2 weeks ago and has been feeling progressively worse. Patient has also reported some urinary frequency, but she has been attributing it to her recent childbirth.

Past medical history

  • Tonsillectomy, age 5 years
  • Epstein-Barr virus, age 14 years
  • Reports a “precancerous mole” that was removed at age 18 years with no complications
  • Gave birth to first child 3 months ago with no complications

Pertinent family history:

  • Mother alive and healthy at age 58 years
  • Father alive, patient reports he takes medication for blood pressure but otherwise is healthy at age 59 years
  • Patient has no siblings
  • Maternal Aunt alive, living with multiple sclerosis, age 54 years
  • Paternal grandfather died after suffering a stroke 2 years ago

Pertinent social history:

  • Former smoker, patient quit at age 23
  • Recently moved to Columbus, Ohio from Toronto, Canada
  • Social drinker with approx. 1-2 alcoholic beverages per week
  • Patient is an artist, enjoys going to the gym 2-3 times per week, and is currently working part time in an art gallery
  • Patient likes being outdoors and states she recently returned from a several day hiking trip

Allergies:

  • None known to patient

Medications:

  • Pt states takes Tylenol “occasionally only for headaches”

Focused physical exam:

  • Height 5′ 6″
  • Weight 135 lb.
  • Skin: clear with no lesions or rashes
  • Heart Sounds: S1, S2 Regular
  • Lungs: Clear in all fields, respirations regular and unlabored
  • Abdomen: Soft, nontender, active bowel sounds. Pt reports last BM was this morning.
  • Genitourinary: Patient reports urinary frequency, states urine is clear and yellow with no foul odor
  • Patient is alert, oriented x 4 to person, place, time, situation
  • Pupils are equal, round, and reactive
  • Strength equal bilaterally in all extremities, patient has a slight intention tremor present in both hands
  • Patient reports feeling “pins and needles” in her left and right lower legs
  • Distal pulses are palpable in all extremities with no abnormalities

Vital Signs:

  • Temperature: 37.0 degrees celsius
  • Pulse: 60
  • Respiratory rate: 18
  • Blood pressure: 108/76
  • Oxygen saturation: 99% on room air
  • Pain: 0/10 pt states: “No pain, I just feel tired and my legs are tingling”

Lab Values/Imaging:

  • CBC: unremarkable
  • Antinuclear antibodies (ANA) test: negative
  • Enzyme-linked immunosorbent assay (ELISA) test: negative
  • EKG: NSR
  • Urinary analysis: unremarkable
  • Urine culture: pending
  • CT Scan: unremarkable
  • MRI with IV contrast: results are positive for inflammation in areas of the brain and spinal cord