Case Study: Progressive Neurological Deficits in a 17-Year-Old Female

Case at a Glance

A 17-year-old female presents with a 2.5-week history of a persistent left-sided headache, profound fatigue, and new-onset neurological symptoms, including intermittent speech difficulties and ataxia.

Patient's Story

The patient is a 17-year-old female who presented to her primary care physician with concerns about a constellation of symptoms that began approximately two and a half weeks prior. She reported a constant, mild headache localized to the left side of her head. More alarmingly, she described episodes of difficulty forming sentences, word-finding trouble, and occasional slurring of speech. She also noted significant balance issues, describing the sensation as being 'drunk.' These symptoms were accompanied by overwhelming fatigue and low energy, causing her to spend most of her days in bed. The patient has a self-reported history of severe health anxiety and expressed significant fear about a serious underlying condition.

Initial Assessment

Upon initial consultation, the patient was alert but appeared lethargic and anxious. She described her symptoms coherently despite reporting intermittent speech issues. Her chief complaints were the left-sided headache, ataxia-like symptoms, intermittent dysarthria/aphasia, and severe fatigue. Given the recent onset and the nature of the neurological symptoms, particularly the speech and balance disturbances, a simple tension headache or typical migraine was deemed less likely.

The Diagnostic Journey

The primary care physician recognized the presence of multiple 'red flag' symptoms. While acknowledging the patient's history of health anxiety, the objective neurological signs could not be attributed to anxiety alone. The physician concluded that the combination of headache with focal neurological deficits warranted an urgent and thorough investigation. An immediate referral to a neurologist was made for a comprehensive neurological examination. The consulting advice emphasized that while the headache itself might be benign, the associated speech difficulties were the primary driver for advanced imaging.

Final Diagnosis

A final diagnosis is pending. The differential diagnosis is broad and includes complex migraine with aura, a primary demyelinating process (e.g., multiple sclerosis), an intracranial lesion, or a functional neurological disorder, among other possibilities. The diagnostic workup is aimed at ruling out serious structural or inflammatory causes.

Treatment Plan

The immediate plan is diagnostic. The patient is scheduled for a comprehensive neurological examination to formally characterize the deficits. A brain MRI with and without contrast has been ordered to assess for any structural abnormalities, inflammation, or vascular issues that could explain her symptoms. Initial management involves symptomatic relief for her headache while awaiting definitive test results.

Outcome and Follow-up

The patient is to follow up with the neurologist immediately after the MRI is completed to review the findings and determine the next steps. Close communication between the primary care physician and the neurologist is being maintained. The patient and her family have been counseled on the diagnostic plan and the importance of monitoring for any worsening of symptoms, such as increased headache severity, persistent speech loss, or significant motor weakness.