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HPI: A 28 yo female presented to the ED with a two to three day history of progressive difficulty walking, double vision, and slurred speech. She complains of a very mild diffuse headache and reports paresthesias of the face, hands, and feet. Her husband states they were exposed to a cleaning solvent containing trichlorethane in the last two days.
Review of systems: She reports having some cold symptoms during the preceding week. There is no history of fever, cough, chest pain, SOB, trauma, abdominal/GI symptoms, or urinary symtoms. Denies any unusual ingestions or recent travel. Immunizations are up to date.
LMP: 9 days prior-normal.
Past Medical Hx: Negative.
Past Surgical Hx: None.
Medications: None
Allergies: None
Social Hx: Married, nonsmoker, physician
Physical Exam:
Vital Signs: T 98.5, p 96, r 20, bp160/100
general: alert, cooperative, in mild distress
skin: warm, dry, (-) cyanosis
HEENT (-) conjunctival pallor, (-) scleral icterus, mucous membranes moist
NECK:(-)tenderness, (-) meningeal signs
CHEST (-) rales, (-) rhonchi, (-) wheezes; breath sounds equal bilaterally
HEART: regular; (-) murmur, (-) gallop
ABDOMEN: Soft; (-) tenderness
EXTREMITIES: (-) edema
NEURO: PERRL, (+) diplopia in all fields, EOMI, no obvious dysconjugate gaze, tongue midline,(+) slurred speech, no facial asymmetry, hearing nl, 5/5 strength in arms and legs, sensory exam nl, somewhat ataxic finger to nose, equally present in both hands, Rhomberg drifted to the right, too unsteady to walk, muscle tone wnl, reflexes 3+ and symmetrical, babinski's plantar bilaterally.
Laboratory Tests
Na 141, K 3.6, Cl 105, BUN 11, GLU 105, SGOT 39, Cr 0.9, PT 12, Hgb 16, WBC 11,200
ESR 5
LP was performed, initially bloody, but cleared...
CSF: glucose 54mg/dl (45-74), total protein 59 mg/dl(15-45), tube 3 -clear, colorless,cell count rbc 51, wbc 1 (a lymphocyte), oligoclonal band absent, IGG 4.4mg//dl (13.4- 23.7) /serum 3870 (3350-4765) = CSF IGG index 0.47 (0.3-0.7), smear neg for organisms, cultures neg, cryptoccocal AG neg.
Stat MRI was negative
The next day the patient a left lateral gaze palsy.
What is your diagnosis?
Answer is due by May 10th.