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Washington University Experience | MYELIN (IMMUNE-MEDIATED) | MS - Cerebral Hemispheres | 5A0 Case 5 History
Case 5 History ---- This patient was a 77-year-old woman with a history most consistent with secondary progressive MS characterized by profound weakness requiring a wheelchair, neurogenic bladder and cognitive issues. She also had bilateral trigeminal neuralgia s/p two surgeries. She initially had a relapsing remitting course from age 36 to 39 with episodes of disequilibrium, an episode of left eye retrobulbar optic neuritis, and Lhermitte’s sign, all of which resolved. In 1980 at age 39, she began to develop chronic symptoms – first fatigue and headaches, and at a later point severe right-sided weakness and numbness. These continued until her disease became progressive in the mid-2000s, with worsening upper body weakness and memory difficulty. Though there were minor fluctuations, her exam from 2008-2011 was generally characterized by bilateral internuclear ophthalmoplegia, bilateral upper extremity weakness – greater in the right than the left with little functional use of RUE, profound RLE weakness, moderate LLE weakness, and decreased vibratory sensation in bilateral LE. Her last available electronic medical record was from 2011. Her recent neurological status, as well as events leading up to her death, were not available in the electronic medical record.
