Step 2

Neurology 6

A 58-year-old woman presents to her primary care physician with complaints of several weeks of progressively worse fatigue, bilateral lower extremity paresthesias, and feelings of unsteadiness while ambulating. Past medical history is significant for gastroesophageal reflux disease, for which she takes pantoprazole. She became vegetarian about five years ago. The patient denies headache, fever, chills, bowel or bladder incontinence, or nausea. She reports additional symptoms of occasional loss of appetite and lightheadedness. Vital signs are temperature 36°C (98.6°F), blood pressure 110/78 mmHg, pulse 61 beats/min, and respirations 19/min. Body mass index (BMI) is 25 kg/m2. Physical examination reveals diminished sensation in the bilateral lower extremities, muscle stiffness, loss of bilateral ankle reflexes, and a positive Romberg sign. Additionally, conjunctival pallor is noted. Lab values are as follows:

  • Hemoglobin (blood): 9.4 g/dL
  • Hematocrit: 32%
  • Mean corpuscular volume: 120 um3
  • Platelet count: 140,000/mm3
  • Leukocyte count: 3,900/mm3

Which of the following is the most likely diagnosis?

  • A) Friedrich ataxia
  • B) Iron deficiency anemia
  • C) Subacute combined degeneration
  • D) Transverse myelitis
  • E) Vacuolar myelopathy


Ria Patel


Dr. Ted O’Connell

Last updated

Jan 07, 2023


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