Chief Complaint: “I’ve had numbness in my legs and toes for months that would come and go”
History of Present Illness: Ms. JP is a 30 year old Caucasian female who presented to her primary care provider with complaints of numbness in her lower extremities that progressed to her hands and waist over the past year. She recently presented to PCP with flu-like symptoms that has just resolved. Last week she went on a run and stated, “When I would run, my legs would go numb and I would just fall”. The patient also complained of double vision, pain behind the eyes, and urgency with difficulty urinating.
Past Medical History:
- Recent Influenza viral infection
- Vitamin D deficiency diagnosed at age 22
- Near sightedness diagnosed at age 12
- Mother has hypothyroidism and high blood pressure
- Father has high blood pressure
- Brother has Ulcerative Colitis
- Current high school history teacher
- Never Smoker
- Social drinker
- Sexually active
No known allergies
- Birth Control
- Vitamin D – 2,000 IU
Ms JP is a slender, well-groomed Caucasian female that presents to the clinic with a worried expression. She speaks clearly and logically and states her chief complaint.
- Vital Signs:
- BP: 112/72, HR: 75, RR: 18, Temp: 98.3 F, O2 Sat: 99%
- Pain: 8/10 pain behind both eyes and in eyeballs
- Neurological: Alert and oriented x4, purposeful motor response, strong hand grip strength, strong dorsiflexion and plantar flexion, pupils 3 mm, brisk and equal pupil reflex in right and left pupils, no hand or leg drift, and a normal gait.
- Ex WNL: Paresthesia in bilateral lower extremities, Diplopia, lack of patellar reflex in the right leg, no numbness and tingling in bilateral upper extremities
- Peripheral Vascular Exam: Capillary refill less than 3 seconds, good skin turgor, +2 radial, popliteal, and dorsal pedis pulses bilaterally.
- Cardiac: Apical and Radial pulse regular, S1 and S2 heart sounds, no murmur detected
- Respiratory: Clear and equal bilateral breath sounds in the Anterior and Posterior
- Genitourinary: Denies pain when urinating
- Ex WNL: hesitancy urinating
- Gastrointestinal: flat abdomen with regular contour, no tenderness upon palpation
- Ex WNL: hypoactive bowel sounds, constipation (last BM 10/22)
- Skin: no discoloration or bruises, intact