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Medical History Questionnaire Date Updated: 21 Feb 2010
1. Basic Personal Data
Sex Female
Age 26
Height 5'8"
Weight 155 lbs
Occupation Electrical Engineer
Marital Status Single
2. Current Symptoms
When listing symptoms, describe using the "what, where, when" questions as outlined below:
What exactly is your symptom and how severe is it: does it prevent you to eat, sleep, walk, etc?
Where exactly does the symptom appear, and, if pain, does it radiate to other parts of the
body?
When did the symptom first appear, did it appear slowly or suddenly, is it present all the time,
how long does it last after it appears?
What triggers the symptom (food, exercise, body position, environmental temperature, etc.)
and what relieves it (rest, medication, etc.)?
GENERAL: fever, feeling cold, pain, tenderness, lightheadedness, dizziness, nausea, weakness,
tiredness, unexplained weight gain/loss, sleeplessness, mood change, etc.
Symptom Description
Lightheadedness Prevents much walking. Fall down sometimes. Nausea rarely leads to
Nausea vomiting. Symptoms first appeared suddenly on 9/11/09 while working on
Dizziness computer. Once appeared, symptoms lasted and did not go away. Have
Weakness not noticed any triggers and nothing relieves symptoms.
SKIN: dry skin, excessive sweating, hot flashes, body odor, itch, paleness, discoloration, rash,
non-healing wounds, bleeding, etc.
Symptom Description
none
HEAD: headache, facial pain, itchy face, itchy scalp, hair loss, etc.
Symptom Description
Headache Headache first appeared suddenly on 9/11/09. Intense pain on one side.
Headaches persisted for months. Medicine like morphine or toradol would
help reduce severity, but not eliminate headache.
NEUROLOGICAL: seizures, unconsciousness, unusual sensations, tingling or numbness,
impaired balance, cognitive problems, etc.
Symptom Description
Numbness Tingling/numbness suddenly appeared in my face, tongue and the right
side of my body on 9/11/09. The numbness in my face and mouth would
come and go, but the numbness in my hand and arm persisted. Nothing
would relieve the symptom, and the areas with numbness felt weak.
Dizziness The dizziness appeared suddenly, again on 9/11/09. It is severe enough to
prevent driving and to reduce the amount of walking considerably. Fast
movements make it worse. Nothing helped relieve the symptoms except
lying down helped a little. Intense nausea and occasional vomiting would
accompany the dizziness.
Word finding Again came on suddenly on 9/11/09. I could think of things to say, but not
be able to say them. Just saying a simple sentence would take a couple of
minutes. This was the most intense on 9/11/09 as it made it very difficult
to speak at all. Since then, the word finding difficulties have been
infrequent.
Sensitivity to cold Body became very cold to the touch. Extremities even turned bluish.
Hands and feet in particular become very cold to the touch very quickly.
EYE: blurred vision, itchy eyes, dry or wet eyes, swollen eyes, eye pain, dropped eyelid, etc.
Symptom Description
Vision loss Lost all right-sided vision suddenly on 9/11/09. This went away, then
reappeared twice again in the next few weeks. The vision loss lasts for
approximately 20-30 minutes, then becomes blurry before I can see
normally again. The vision loss is always followed by an intense headache.
Droopy eyelid Along with the facial numbness, my eyelid would sometimes droop.
NOSE: nasal congestion, nasal discharge, sneezing, nosebleed, changed sense of smell, etc.
Symptom Description
none
EAR: ringing in ears, ear discharge, pressure in ear, impaired hearing, etc.
Symptom Description
Sensitivity to Frequently sounds that would normally not bother me would seem
sound unusually loud.
MOUTH: bad breath, mouth ulcers, drooling, tingling lips, etc.
Symptom Description
none
THROAT: itchy throat, etc.
Symptom Description
none
MUSCLE: muscle cramps, tremor, etc.
Symptom Description
Twitching Various muscles all over my body will twitch for a few minutes. It happens
frequently inside my ribs and hands. It happens all day with different
muscles. Body position does not affect it.
RESPIRATORY: difficulty breathing, wheezing, cough, etc.
Symptom Description
none
HEART: rapid, slow or irregular heart rhythm, palpitations, chest pain, etc.
Symptom Description
none
GASTROINTESTINAL: poor appetite, excessive hunger, nausea, heartburn, vomiting, hard or
painful swallowing, abdominal pain or cramps, bloating, loose stools, mucus or blood in stool,
urgency, incontinence, constipation, etc.
Symptom Description
none
URINARY: change in amount, color or smell of urine, blood in urine, etc.
Symptom Description
none
LIMBS: pain, weakness, cramps, swelling, painful joints, reduced mobility, etc.
Symptom Description
Weakness I have the feeling of weakness in the right side of my body, that corresponds
with the numbness. However, I am not sure the muscles are actually
any weaker because I can grasp and hold things as usual, it just feels weak.
To correlate with Rajeev's list, indicate by letter which of the following symptoms you have
experienced.
A - Confusion C - Tremors
B - Disorientation D - Psychosis, Hallucinations
E - Monoclonal Jerks J - Coordination, Fine Motor
F - Concentration, Attention Span, Short Movements Issues
term Memory issues K - Right sided issues
G - Seizure, Convulsions L - Aphasia, Word finding, Articulation
H - Dementia, Memory Loss Issues
I - Fatigue M - Other (Please Provide a Description)
A, B, E, F, I, J, K, L, M (vision loss, headaches)
3. Time Course of your Current Disease
Tests with results and diagnoses given by doctors, therapies you have tried and their effect.
9/11/09: Went to ER with all symptoms outlined above. Was diagnosed with complex migraines. No
tests performed. Prescribed Phenergan 25mg for nausea.
9/28/09: Went to PCP with persistent headache, nausea, dizziness and numbness. Dr. agreed with
diagnosis of migraines. Indicated I may be experiencing recurrent migraines. Referred to neurologist.
10/08/09: Went to ER with severe headache, nausea, dizziness and numbness. CT Scan normal.
Prescribed Fioricet for headache and Zofran 4mg for nausea.
10/10/09: Went to ER with severe headache, nausea, dizziness and numbness. MRI of brain and MRA
of neck were normal. Note is made of a tiny retention cyst within the medial right maxillary antrum.
Vitals normal: bp 122/72, pulse 64. Physical exam normal. Lab results normal except for CBC Auto
Neuts = 47.0 (low); Auto Lymphs = 45.1 (high); Metabolic CL = 109 (high).
Diagnosed again as complex migraine. Prescribed Oxycodone-Acetaminophen 5-325 mg for pain and
Metoclopramide HCL 5mg for nausea.
Dizziness, nausea and headaches have now caused me to be unable to attend work.
10/16/09: Went to neurologist for symptoms of headache, nausea, dizziness and numbness. Diagnosed
with complex migraines. Prescribed methylprednisolone 4mg 6-day pack and metoprolol SUCC ER 25mg
for migraines. Given trials of Maxalt and Treximet for migraines.
Did not experience another symptom of vision loss after the steroids. Numbness also decreased.
Severe headaches, dizziness and nausea persist. Migraine specific medicine does not appear to help.
Metoprolol has slowed heart rate and lowered blood pressure. Dizziness has actually increased.
11/06/09: Nerve conduction study and EMG performed to diagnose cause of numbness. Mildly
abnormal left median motor NCV due to a mildly prolonged distal latency. Normal left median sensory
NCV. Mildly abnormal left ulnar sensor NCV due to a mildly prolonged distal latency. Normal left ulnar
motor NCV. Normal right median motor and sensory NCVs. Normal right ulnar motor and sensory
NCVs. Normal right and left radial sensory NCVs. Normal right arm EMG. Comment: Part of the
slowing was due to the fact that the patient vasoconstricted quickly, sweated and chilled. This
compromised the study and contributed to the slowing of all nerves tested.
11/11/09: Neurologist ordered blood tests because symptoms will not subside. He believes it could be
more than just migraines.
Blood test showed elevated anti-thyroid peroxidase antibodies suggesting Hashimoto's-related
neurologic syndrome. Anti-thyroid peroxidase was 2428. Anti-thyroid globulin was 133.
11/12/09: Went to ER with severe headache, nausea, dizziness and numbness. Prescribed Toradol for
pain.
11/13/09: Visited neurologist due to headache pain being too severe. He diagnosed me with
Hashimoto's Encephalopathy. Since the pain was debilitating, he ordered 5 days of IVIG treatment as an
inpatient. The IVIG did not alleviate any symptoms at all. I was receiving IV Toradol for the pain.
11/20/09: Neurologist prescribed Prednisone 30mg per day. Symptoms began to improve. Numbness
disappeared. Headache severity improved, but constant headaches persisted. Dizziness and nausea
improved only slightly.
It was later discovered that the pharmacy had mistakenly given me half the dose the doctor prescribed.
I was supposed to take 60mg per day, but was only taking 30mg.
12/02/09: Headache pain became too intense to bear. Neurologist admitted me for 3 days of IV
steroids, 500mg methylpredisolone twice per day, each dose infused over 1 hour. I was taken off of the
metoprolol. The next day I was able to walk in a straight line for the first time in months. It appears the
steroids were helping, and the dizziness was in large part due to low blood pressure from the
metoprolol.
After the 3rd dose of the steroids, I went into a short episode of ventricular tachycardia. The next
morning, I got out of bed and nearly passed out. My heart rate went over 145 bpm just from getting out
of bed. My heart rate was irregular and fast, so I was confined to bed. I had to receive Heparin shots in
the belly due to prevent DVT.
I continued to receive the steroids. The side effects were: fast heart rate, short of breath,
lightheadedness, heartburn, headaches, dry mouth/increased thirst, shaking like shivering
Discharged with prescription for 60mg Prednisone per day and Nexium 40mg for the heartburn.
12/08/09: Heart rate was very high, which was causing breathing difficulties and lightheadedness. EKG
showed slightly abnormal rhythm. Sinus rhythm, right atrial abnormality. Doctor said he had not seen
this caused by steroids before, but it is not life threatening.
Chest X-ray was normal.
12/11/09: Neurologist ordered 24 hour urine creatine test and corresponding blood test blood test. No
results yet.
Cardiac stress test performed. Results appeared normal except for a higher than normal heart rate.
Resting heart rate was 100 bpm. Test reached 100% of target heart rate without signs of tachycardia.
Nurses told me the high heart rate was likely due to the steroids. They indicated my body could be
adjusting after coming off Metoprolol as well.
12/12/09: Beginning to feel better. Heart rate still high, but not erratic. No sign of numbness or
cognitive problems. Headache severity improving. Dizziness and nausea improving. It appears the
steroids are working slowly. Able to return to work.
12/17/09: Creatinine test showed no sign of renal problems. Slightly higher than normal creatinine
clearance, indicating high production of urine. 24 hour urine collected 3700 ml. Determined increased
urine production not harmful, cause unknown. Complaint is constant thirst and dry mouth.
Blood tests showed TPOAb currently at 1625. Improvement from 2428 from initial blood tests.
Discussed remaining on 60 mg Prednisone per day since it is slowly but steadily improving symptoms.
Prescribed physical therapy to relieve tension in neck that is likely causing tension headaches.
Referred to Ear, Nose and Throat doctor to evaluate retention cyst in sinus found on MRI. Cyst could be
contributing to headaches.
12/28/09: Experienced Right sided vision loss with headache. High stress at time and prior to vision
loss. Symptoms resolved within an hour. Was prescribed Xanax for anxiety while flying. 1 mg helped
significantly to reduce anxiety while flying. Also helped reduce symptoms such as numbness, shaking
and racing heartbeat. Possibly developed anxiety disorder? Will discuss with doctor. Vacation and
reduced stress also helped with symptoms. Now taking 1 mg Xanax in morning, then 0.5 mg twice per
day which appears to significantly improve symptoms and quality of life.
01/08/10: Went to Mayo Clinic and saw Endocrinologist Sydney Westphal. Prior to appointment, I was
told she was an expert in HE. She reviewed my files and did not want to take me as a patient. She said
my TSH levels were within normal range, so she couldn't treat my thyroid. She said I am at high risk for
thyroid disease, but told me to just get my levels checked annually. I asked her a second opinion on my
HE treatment, but she said HE is a "controversial" condition and it was not for her or any endocrinologist
to treat. She said it is for a neurologist to comment and treat. She ordered blood tests at my request.
B12 was 378ng/L in normal range (I do take B12 supplements). Glucose was 76 mg/dL which is on the
low end of normal. Calcium was 10.0 mg/dL which was the high end of normal. TSH was 1.51 mIU/L,
range is (0.03-5.0) so it was within normal range. Hydroxy Vit D2/D3 was 24 Ng/ML which was just
slightly lower than normal range of (25-80). TPO Antibodies were 98.8 IU/mL which is very high
considering normal is below 9.
01/12/10: Had appointment with Dr. Estevez. Had been sick with cold like symptoms, a cough and
cloudy urine for the past week. Dr. attributed it to bronchitis and a UTI, so prescribed Cipro. After 2
more days the cough and mucus passed, but the cloudy urine remains. Anxiety and panic attacks
remain consistent. Dr prescribed Klonopin 0.5mg twice a day instead of the Xanax. However, the
Klonopin isn't working at all to control anxiety symptoms. I still take 1 mg Xanax when a panic attack
hits. Dr and I discussed continuing on Prednisone 60 mg for one more month before beginning a taper
down. Once I have tapered off steroids completely, we will attempt IVIG monthly. I expressed interest
in the Lumbar Puncture to check the antibodies in the CSF, but he declined considering the risk of
infection. Prescribed injectible B12, 400IU Vitamin E, 400IU Vitamin D, 1000mg Flax Seed, and 1000mg
Vitamin C
01/19/10: Had appointment with PCP Dr. Hornback. Cloudy urine still remains, so he did urine culture.
He said urine is very concentrated and has a bit of blood, but blames that on the steroids. He will also
send it for culture. He believes my anxiety and panic attacks are steroid induced and will decrease with
the decrease of the steroids. He will speak with Dr. Esteves about upping the Klonopin dosage, as he
believes it is too low. He also mentioned different mood stabilizers to help with the anxiety. He also
mentioned talking to Dr. Extevez about going on different immune suppressants rather than Prednisone.
He agreed with most of Dr. Estevez' supplement dosages, except he thinks the oral B12 is sufficient and
he recommended 2000IU Vitamin-D3. He made a referral to an opthomologist for the eye pressure. He
said the cyst surgery, corn surgery and LP will have to wait until I am off the steroids. I have gained 7
pounds total, 4 since last appointment.
1/25/10: Called into PCP because it appears the Cipro caused thrush. PCP prescribed flucanazole
100mg for 2 weeks and "magic mouthwash" to use every 6 hours, or more often if sure not to swallow
any.
1/28/10: Had appointment with PCP Dr. Hornback. Concerned because the white stuff has been
decreasing, but lesions, throat pain and a persistent, dry cough worsened. Dr. Checked on my thrush
and agrees that the fluconazole and magic mouthwash is working, but it will take at least several days
before I get relief. He has yet to speak with Dr. Estevez about changing the mood stabilizers, but he
maintains in the mean time it is safe to take 1mg Klonopin twice per day and occasionally take a Xanax
in addition as needed. My biggest complaint is the anxiety while driving. He suggests some other longer
acting mood stabilizers, but he will want to consult with Dr. Estevez. Lost 6 pounds. Back down to 155.
1/30/10: Had appointment with Ear, Nose, Throat doctor, Dr. Kang to evaluate cyst in sinus cavity. He
said the cyst was too small to be causing any problems like headaches and he recommended I just live
with it. I asked about my cough associated with the thrush and he said it was normal. Thrush in adults
can be very severe and a cough is normal.
2/12/10: Thrush appears to be gone. Headaches persist despite physical therapy every week. It
appears tension in neck is beginning to relieve some, but headaches persist. Body aches have
worsened.
Went to opthamologist Dr. Calonje to evaluate feeling of eye pressure and losing vision focus. Pressure
test was normal. Left eye was 19, right was 20, range is 17-25. This meant no signs of glaucoma. Doctor
saw no signs of cataracts. He said my eyes were very dry and that was likely causing the pressure and
focus problems. He gave me eye drops (Systane) and said to use over the counter eye lubrication drops,
but not Visine. He remarked how good I looked considering the high dose steroids I have been on for so
long, but said I will almost certainly develop cataracts if I continue the steroids for a long period. He
recommended annual checks for cataracts.
Have not needed Xanax for 3 days. Klonopin appears to be controlling the anxiety fairly well. I still have
several moments per day of feelings of anxiety with racing heartbeat and sweating, but I can calm down
on my own most of the time. Driving is still difficult, but I am driving daily.
I remembered February 2009 may have been my first HE episode. I was driving and went numb on my
right side, then began to have terrible vertigo with nausea. Had to pull over the car and stop driving.
Had these symptoms and severe headache all day. Began to feel better that night and took 2-3 days to
feel back to normal. Had thought it was dehydration, but likely was an HE episode.
2/18/10: Went to appointment with neuro Dr. Estevez to begin prednisone taper. I expressed that I
was terrified to taper too quickly to risk symptoms returning. We agreed that I would begin the taper on
2/19/10 by 10mg increments every 2 weeks. So I will be on 50mg for the next two weeks, then go down
to 40mg for 2 weeks, and so on. My next appointment is on 3/22/10 and I should be on 30mg of
prednisone. I also had a blood test done to check the antibodies and my Vitamin D levels before the
taper begins.
I started noticing slight menstrual spotting. This has never happened to me before. I began taking
Acidophilus and the spotting reduced the next day.
On 2/20/10, I began to have panic attacks more regularly again, especially while driving. Both hands go
numb, my heart races and I have speedy breathing. Xanax appears to help. I think I am just scared for
the taper and I am having more anxiety than normal.
Headaches and body aches persist. Skin has thinned considerably and cuts and cracks very easily.
4. Complete Personal Medical History
Childhood and other diseases, injuries, allergies, symptoms, investigations (with results), diagnoses,
vaccinations and therapies (and their effect) from birth to present.
No history of serious illness. Car accident in 2004 leading to mild reversal of the normal cervical
lordosis. MRI, CT and EEG otherwise normal. Physical therapy helped restore strength and range of
motion. Causes occasional tension headaches.
Dust allergies and skin sensitivity to fragrances and dyes.
5. Current Medications
Current prescribed and over the counter medicines, supplements, physical or other therapy.
Daily:
Claritin 10 mg tablet
1 tablet per day
Tri-Lo-Sprintec
1 tablet per day
Prednisone 20 or 10 mg tablet
currently at 50mg daily
Nexium 40 mg tablet
1 tablet per day
Clonazepam 1 mg tablet
1 tablet twice per day
Vitamin D3 400IU tablet
2 tablets per day
Vitamin E 200IU capsule
2 capsules per day
Flaxseed 1000 mg capsule
1 capsule per day
Vitamin B12 1000 mcg
dissolve 1 under tongue once per day
Acidophilus
one tablet per day
Systane lubricant eye drops
one to two drops in each eye as needed
As Needed:
Promethazine 25 mg tablet
1 tablet every 4 hours as needed for nausea and vomiting
Ondansetron ODT 8 mg tablet
1 tablet 3 times daily as needed
Butalbital-APAP-Caffeine 50-325-40 mg tablet
1 to 2 tablets every 4 hours as needed for headache
Alprazolam 1 mg tablet
1 tablet twice per day
Physical therapy - c-spine traction and heated massage once per week
6. Life Style
Physical activity, diet, stress, living conditions, smoking, alcohol, street drugs
No alcohol, smoking or street drugs. Healthful, balanced diet. Frequent stress at work as electrical
engineer. Lives with boyfriend and 1 dog in townhouse.
Prior to 9/11/09 very active. Heavily involved in outdoor exercise such as hiking and rock climbing.
Frequent, rigorous exercise. Since 9/11/09 rather inactive due to symptoms. Have not done any
rigorous exercise since 9/11/09.
7. Family History
Does any of your close relatives (sisters, brothers, parents, grandparents, children, uncles, aunts)
have/had any of the following diseases:
o Allergies
o Cancer
o Diabetes brother
o Heart problems
o Stroke
o Thyroid problems mother (hyperthyroidism), cousin (thyroid cancer)
o Autoimmune disorders
o Psychiatric disease
o Other chronic disease sister (Muscular dystrophy)
If any of your close relatives has died, at what age and from what cause has he or she died?
None
