Differential Diagnosis

The patient presents with a combination of neurological symptoms, including trembling fingers, muscle twitching, pulsating sensations, and memory issues, which have been ongoing for about a year and a half. Despite investigations, including MRI scans and a rheumatologist's evaluation, no clear cause has been identified, leading to a consideration of stress as a potential factor. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis
  • Stress Response or Anxiety Disorder: The patient's symptoms, such as trembling, muscle twitching, and memory issues, can be associated with high levels of stress, especially considering the patient's history of depression and current stressful life situation with two toddlers. The absence of findings on MRI scans and the rheumatologist's evaluation, along with the variability of symptoms (weeks where the patient feels symptom-free), supports this possibility.
• Other Likely Diagnoses
  • Fibromyalgia: Characterized by widespread musculoskeletal pain, fatigue, sleep, memory, and mood issues, fibromyalgia could explain some of the patient's symptoms like muscle twitching, pulsating sensations, and memory problems. The "bubbles popping" sensation in the legs could be related to the paresthesia experienced by some fibromyalgia patients.
  • Vitamin Deficiencies (e.g., Vitamin B12 Deficiency): Deficiencies in certain vitamins, particularly B12, can lead to neurological symptoms such as tremors, muscle weakness, and memory problems. Given the patient's symptoms and the fact that these deficiencies can sometimes be overlooked, this is a plausible consideration.
• Do Not Miss Diagnoses
  • Multiple Sclerosis (MS): Although the patient has undergone MRI scans, including one of the spine, which did not show evidence of MS, it's crucial not to completely rule out this diagnosis without further consideration. MS can present with a wide range of neurological symptoms, and its diagnosis can sometimes be challenging. The patient's symptoms, such as pulsating sensations and muscle twitching, could potentially be related to MS, especially if the scans were not conclusive.
  • Thyroid Disorders: Both hyperthyroidism and hypothyroidism can cause neurological symptoms, including tremors, muscle weakness, and memory issues. The patient's hair loss also points towards a potential thyroid issue. It's essential to rule out thyroid disorders with appropriate blood tests.
• Rare Diagnoses
  • Wilson's Disease: A rare genetic disorder that leads to copper accumulation in the body, causing neurological symptoms, liver disease, and psychiatric problems. Although rare, it's a condition that could explain some of the patient's neurological symptoms and should be considered, especially if other diagnoses are ruled out.
  • Peripheral Neuropathy: This condition results from damage to the peripheral nerves and can cause a variety of symptoms, including pain, numbness, and tingling in the feet or hands. It might explain some of the patient's sensations, such as the "bubbles popping" feeling, but would typically require specific diagnostic tests for confirmation.

Given the complexity and variability of the patient's symptoms, a comprehensive approach that includes further diagnostic testing, lifestyle modifications to manage stress, and possibly a trial of therapies aimed at stress reduction and symptom management may be necessary. Consulting a neurologist for a detailed evaluation and to discuss the possibility of further testing or referral to other specialists could provide more clarity on the patient's condition.