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fatigue, weakness, disequilibrium, insomnia, ataxia.....

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PROBLEM: fatigue, weakness, disequilibrium, insomnia, ataxia, anxiety, feel like feinting. Mild depression due to symptoms. Started intermittently about three years ago, now 24/7, but it is worse in the afternoon. Work is becoming difficult and full time almost impossible. Have an overwhelming sense of collapsing and struggling to remain rigid and strong, especially bad at work (mostly sat in front of a computer, with multi-tasking and interaction with other people). Fatigue is probably the best one-word description. I get probably 4-5 hours intermittent sleep at night. Never nap during the day.
BASICS: 54 year old male. BP 107/66, pulse 58, Ht 5' 10” Temp 97.9F Wt 185 lb. No history of trauma or serious illness. No numbness, no pain, no headaches, no tobacco, moderate to excessive alcohol, now much reduced. Stopped caffeine. Have seen many doctors – summary as follows:
NEUROLOGY: The patient is well-developed, well-nourished, cooperative, without acute distress. General exam otherwise unremarkable. He still has generally poor sleep and daytime fatigue. Trying sleep hygiene but this is insufficient. Some unsteadiness, but no falling. MS: Alert and oriented x3 with intact language, memory, and cognition CN: EOMI, no ptosis, no nystagmus, face symmetrical, no dysarthria Motor: No drift. Coordination: Intact gait, intact tandem gait, negative Romberg Cranial Nerves: 2-12 Intact. Specifically had EOMI, no nystagmus, PERRL, normal sensation V1-3, tongue and uvula midline. No tongue atrophy or fasciculations. Fundiscopic exam with normal vessels and without papilledema bilaterally. Strength is 5/5 throughout and without fatigue. FFM intact bilaterally. Intact to soft touch, pin prick, and vibration throughout. Finger to nose with eyes closed intact. Reflexes: DTRs 2+ bilaterally symmetrical throughout. Down going Babinski bilaterally. Negative Hoffman bilaterally. Tested – Calcium 9.3 mg/dL, Magnesium 2.0 mg/dL, Phosphorus 3.6 mg/dL, TSH 1.17 uU/mL, ENA Negative, Rheumatoid Factor <20, Methylmalonic Acid n o inteqretation) 0.10 umol/L, Lyme Negative. Electromyography: The nerve conduction studies were normal. The needle examination was normal. Electeodiagnostic studies of the right upper and right lower extremities were within normal limits. MRI - of the lumbar spine without gadolinium: Findings: The lumbar spine is in normal alignment. There is no evidence of a compression fracture. At LS/S1 the disk is mildly desiccated and there is a tiny central disk protrusion and minimal facet arthropathy without evidence of stenosis. At L4/5 there is a mild posterior bulge and minimal facet arthropathy without evidence of stenosis. The visualized disks are otherwise unremarkable. The distal spinal cord is normal in size and signal characteristics. The conus is at the L1 level and is unremarkable. Incidental note is made of a hemangioma at the L4 level. No paraspinal soft tissue masses are seen. L5/S1 with a tiny central disk protrusion without evidence of stenosis. MRI – Brain w/o: Essentially negative MRI of the brain without intravenous contrast. There were a few nonspecific subcortical white matter foci present. Chest XRAY: The heart and mediastinum are normal. The lung fields and costophrenic angles are clear without evidence of active cardiopulmonary disease. Diffuse degenerative changes are noted throughout the spine with increased dorsal kyphosis. Remainder of the bony and soft tissue structures appear within normal limits.
PRIMARY CARE PHYSICIAN TESTS: General Chemistry: SODIUM 140 mMol/L, POTASSIUM 4.1 mMol/L, CHLORIDE 105 mMol/L, C02 29 mMol/L, ANION GAP 6.0 , OSMO CALC 279, BUN 18 mg/dL, CREATININE 0.8 mg/dL, BUN/CRE RATIO 22.5, eGFR (AFR AMER) >60.0 mL/min, eGFR >60.0, GLUCOSE 86 mg/dL, CALCIUM 8.4 mg/dL, TOT. BILIRUBIN 0.5 mg/dL, ALK PHOS 47 IU/L, ALT 36 IU/L, AST 18 IU/L, T. PROTEIN 7.2 g/dL, ALBUMIN 4.0 g/dL, GLOBULIN CALC 3.2 g/Dl, A/G RATIO 1.3, CHOLESTEROL 211 mg/dL, TRIGLYCERIDES 68 mg/dL, HDL 55 mg/dL, CHOL HDL RATIO 3.8, LDL INDIRECT 142.40 mg/dL. Special Diagnostics: VITAMIN B12 640 pg/mL, TSH 1.960 uII/m, VITAMIN D25 OH 32 ng/mL. Hematology: WBC 3.9 Thou/uL, RBC 4.43 Mill/uL, HGB 14.4 g/dL, HCT 42.4 %, MCV 95.7 fL, MCHC 34.0 g/dL, RDW-SC 47.9 fL, RDW-CV 13.7 %, PLT COUNT 206 Thou/uL, MPV 10.0fL, SEGS 47.6 %, LYMPHS 40.3 %, MONOS 10.3 %, EOS 1.3 %, BASOS 0.5 %, IMMATURE GRANS 0.0 %, ABS NEUT COUNT 1.86 Thou/uL, NUCLEATED RBCs 0.0 Urology: TESTOSTERONE 329 ng/dL, ACETYLCHOLINE REC BINDING AB 0.00 nmol/L, Autoimmune Dysautonomia Eval, S. No informative autoantibodies were detected. Electrocardiography: Sinus bradycardia, otherwise normal.
ENDOCRONOLOGY: ADRENOCORTICOTROPIC HORMONE 18 pg/mL, PSA ULTRA-SENSITIVE 1.78 ng/mL, TSA 3r GENERATION 1.314 uIU/mL, FREE T4 1.1ng/dL, CORTISOL 11.3 ug/dL, CORTISOL, RANDOM (pre-stimulation) 12.5 ug/dL, CORTISOL, RANDOM (post 250ucg cosyntropin) 28.9 ug/dL
SLEEP CENTER: Diagnosed with moderate sleep apnea early 2012, but since then have been using CPAP. Much improvement (before/after): AHI (7.6/0.8).
CURRENT ASSESSMENT: Sleep Apnea, Insomnia and Chronic Fatigue Syndrome. (some neurologists debate this) Current analysis is sleep debt.
TREATMENTS: Tried Lorazepam about 3 years ago but made me feel worse. Tried Unisom but didn’t help sleep much. Have been using Zolpidem ER Ambien CR (12.5 MG) for 8 months with some benefit- improved sleep onset and maintenance, but still only getting about 4 hours at once. I want to believe it is sleep-related. I seem to have more energy in the evening than the afternoons. Now the sleep neurologist is trying Cognitive Behavioral Treatment for Insomnia. I Exercise (bike, yoga, stretching, Thai Chi) all week, total 8-10 hours. B i-monthly psychology visits working on stress, meditation. In many respects I am in my best health is years but this fatigue is overwhelming me and making earning a living difficult.
Is it sleep related? Have I eliminated everything else?


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replied September 26th, 2013
Neurological Disorders Answer A44836
Thank you for detailed history. Sleep deprivation is probably responsible for your fatigue. People with fatigue due to sleep apnea are rather sleepy during the day and tend to feel much better on CPAP if it is well tolerated. It seams to be not your case. I think that the next step is an antidepressant trial. I would try Wellbutrin, Pristique or Lexapro first if I was treating you. You have to discuss it with your doctor though. If you take alcohol at night to sleep better it is the worst you can do. Sleeping pills are not going to help in chronic insomnia. By Andre Strizhak


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