This is a 39 year-old female who developed weakness starting six months ago.
She noted initially that her feet felt unsteady and that her legs became tired
and weak with use, especially climbing hills. This was progressive over the next
month.

After 2 months, weakness began in her arms, particularly lifting things above her head. She has noted shortness of breath with exertion. Chest x-rays have not revealed a cause. Occasional choking and jaw fatigue, with increased time completing meals. She is having difficulty with showering, dressing, getting out of chairs, doing light and heavy housework, preparing meals, and shopping. Review of systems positive for difficulty walking, fatigue, trouble sleeping, feeling sad, anxiety, swallowing difficulties, and weight loss.

She has spondylolisthesis and has a body brace for this, prescribed by an orthopedic surgeon. Back pain is increasing.

PMH:
1. L4-5 spondylolisthesis

Medications:
1. Ibuprofen
2. MVI

Allergies:
1. PCN - rash

Family History: Thyroid disease in her father. Her father also has a slow shuffling gait.

Social History: The patient is a single mom, with a 7-year-old and a toddler. She continues to work at Boeing. She smoked in the past but totally quit this year. She uses three to five alcoholic beverages per week.

Physical:
BP 110/78   HR  92   T 37.20°C   W 187lb
General: Looked short of breath walking to the room.
Mental Status: Alert. Speech was fluent without dysarthria or paraphasic errors.
HEENT: II: PERRLA. III, IV, VI: Extraocular movements are full. V:
Normal facial sensation. VII: Eye closure strength normal. Good smile.
IX, X: Palate elevation is symmetrical in the midline. XI:
Sternocleidomastoid was strong bilaterally. XII: tongue strong without fasciculations.
Motor (Power/Tone/Bulk): No atrophy, fasciculations, or contractures.
Normal bulk and tone throughout. Neck flexion weakness at 4/5, normal neck extension. She requires a push to stand from a chair. There is no scapular winging. In the upper extremities proximal weakness 3/5 and distal weakness 4/5. In the lower extremities proximal weakness 4/5 and distal strength 5/5.
Sensory: Normal to pinprick and vibration.
Reflexes: Trace UE, 1/4 knees, and 2/4 ankles with downgoing toes.
Coordination: Normal.
Gait: Normal.
Abnormal Movements: None.
Other Organs: noncontributory.