A 23-year-old female complains of episodes of blurry vision and ...

[sammy]

A 23-year-old female complains of episodes of blurry vision and numbness and tingling in the left foot. When the foot falls asleep, the patient feels imbalanced and a gait disturbance develops, making the patient fall.
 
  The patient has a medical-surgical history of appendectomy age 10. Otherwise, patient has no history of illness and takes no medications. Denies use of tobacco or alcohol. On physical examination, vital signs are T 98 degrees,18 resps/min, pulse 66, and BP 110/60. Vision: 20/20 os, 20/20 od, and 20/20 ou. Heart: regular rate and rhythm, no murmurs. Lungs are clear to auscultation. Abdomen is non-tender with no organomegaly. Extremities: Skin is pink, cool to touch, and intact bilaterally. Left and right quadriceps muscle strength 5/5. DTRs left and right + 2/4. No clonus. Negative Homan's and Babinski's sign. Sensation to pinprick and cotton ball intact in extremities and equal bilaterally. Dorsalis pedis pulses +1 /4 bilaterally. No neurological deficits. The following disorder(s) should be considered in the diagnosis:
  A. Multiple sclerosis
  B. Peripheral vascular disease
  C. Restless leg syndrome
  D. None of the above

Question 2

When assessing a patient who complains of muscle weakness, the clinician should assess if there is specifically:
 
  A. Bilateral or unilateral muscle weakness
  B. Proximal versus distal muscle weakness
  C. Upper extremity and/or lower extremity weakness
  D. All of the above

[at]

Answer to Question 1

ANS: A
In multiple sclerosis, visual disturbances may be the initial presenting symptom, indicating a plaque on the optic nerve. Associated visual disturbances include diplopia, blurred vision, tunnel vision, scotoma, or amaurosis. The visual changes are usually monocular. The patient may complain of intermittent weakness, parasthesias, or numbness of the face or extremities that occurs intermittently and that may resolve for weeks to months. Patients may report episodes of falling or stumbling with gait ataxia. Hyperreflexia may be noted, particularly in the lower extremities. Other symptoms include bladder incontinence or retention. Spastic bladder may also occur. In later stages, mental status changes may be noted. Initial symptoms are typically intermittent, and the disease may go undiagnosed for months or years.

Answer to Question 2

ANS: D
The history should include the type of weakness, whether it is proximal weakness, which might alert you to thyroid disease, malignancy, or adrenal dysfunction, or distal weakness, which would raise an index of suspicion for a neurological cause especially if it was accompanied by paresthesias. Ask the patient when and with what types of activities the weakness is most prominent and how much it interferes with activities of daily living. Inquire about changes in speech patterns or slurring that might indicate a neurological cause. Ask whether there are any cognitive or personality changes, which are often seen with adrenal dysfunction. The review of systems should include headache, cold or heat intolerance, change in appetite, weight gain or loss, nausea, vomiting or diarrhea, changes in balance or gait, numbness or paresthesia, diplopia or other vision changes, and difficulty with speech or swallowing.

[sammy]

Excellent

[sultansheikh]

TYSM