Patient is an 18-year-old female with a history of multiple sclerosis on ofatumumab presenting with one week of progressive fatigue and hypotension. Parents report home blood pressures as low as 90/70 with associated tachycardia to the 120s and increasing lethargy. She has had decreased oral intake, two episodes of NBNB emesis today, dizziness, and palpitations. Parents also report fevers at home with a Tmax of 104°F, unclear onset. 

She endorses urinary urgency but denies dysuria or hematuria. Yesterday, her family noted yellow discoloration of her hands. She has had two falls due to weakness without head strike, LOC, or injury. She denies headache, upper respiratory symptoms, chest pain, shortness of breath, abdominal pain, diarrhea, or rash 

Of note, she was seen at an outside hospital six days ago and diagnosed with a urinary tract infection, dehydration, and anemia. She was started on nitrofurantoin and iron supplements.  She is currently on day five of antibiotics. 

PMH: Multiple sclerosis, asthma, eczema  

PSHx: None  

Meds: Vitamin D, Ofatumumab (Kesimpta) 

Allergies: NKDA 

Immunizations: UTD 

Physical Exam  

T38, HR 123, RR 17, BP 113/67, 100% on RA 

General: Alert.  Anxious. Nontoxic appearing.     

Skin: Warm. Dry skin. Palmar pallor bilaterally. 

HEENT: Normocephalic.  atraumatic.  Sclera icterus.   

Cardiovascular: Regular rate and rhythm.  No murmur.  Cap refill ~2secs 

Respiratory: No retractions. CTAB.     

Gastrointestinal: Soft.  Non distended.  Mild RLQ tenderness. Negative Psoas and Rovsing sign    

Musculoskeletal: Moving all extremities. No joint swelling.     

Neurological: Alert.  No focal neurological deficit observed.  CN II-XII intact.  Normal sensory observed.  Normal motor observed.  Normal speech observed.  Developmentally normal.  Alert and oriented x3.    

Lymphatics:  No lymphadenopathy