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