A 32-year-old physician had a baby six months prior to the onset of new neurological symptoms. She reports that she has been experiencing intermittent blurred vision and tingling of her left leg for about two weeks. The episodes occur several times per week, and each tend to last for about 5 to 10 hours. She has not had any recent trauma, injuries, or infections, and she does not have any muscle weakness.
Past medical history
The patient is healthy and had a normal pregnancy with a normal labor and delivery. She gave birth to a healthy baby girl six months ago.
The patient has worn corrective lenses for many years and has had problems with her prescription for the past three years, frequently getting her prescription renewed without any improvement. She is in her last year of a medical training fellowship, and she has been doing well at work. She initially thought that her visual symptoms could be related to her work with diagnostic images, looking at them for hours at a time, but she now thinks that the problem is related to her eyes or to a neurological dysfunction. Family history: Her father and mother are in their 50s, and they are good health.
Her blood pressure is 120/65, pulse is 82, and respiratory rate is 16. The patient is alert, oriented x3, and cooperative. She appears in good health and does not have any tremors, jerking, or involuntary movements. Her skin is normal without any lesions or discoloration. Her pulse is normal, and her heart sounds are regular without any murmurs. Her breathing is normal. Her abdomen is non-tender and non-distended.
Her face is symmetric without any weakness or ptosis. Her extraocular movements are normal with no nystagmus. Her pupils are normal, equal, and reactive to light. Her vision is blurred, and she has trouble reading a pamphlet and the sign on the door with her left eye. She can read close-up and far away with her right eye, but her visual acuity was not checked during this visit. On her funduscopic examination, she has normal vessels bilaterally. She has the appearance of inflammation of her left optic nerve, consistent with optic neuritis, and a normal appearance of the right optic nerve.
Her motor strength is 5/5 in bilateral upper and lower extremities. The left patellar reflex is diminished; her other reflexes are normal. Her sensory examination is normal to light touch, pinprick, vibration, and position in all extremities except for diminished sensation to pinprick in her left leg. Her upper extremity coordination is normal bilaterally on finger to nose, and her rapid alternating movements are normal. Her heel to shin testing is normal on the right and impaired on the left. Gait is normal, but she has difficulty with tandem walking.
The patient had a brain MRI, which was normal. She had a lumbar spine MRI, which showed two small areas that were consistent with demyelination in the lumbar spine. She had visual evoked potentials, which were consistent with optic neuritis of the left eye.
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