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N12) Intermittent visual disturbances and weakness in a 29-year-old male
Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.
Learning Outcomes
- Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with weakness.
- Review the DDx considerations in weakness.
- Identify the spectrum of imaging findings in appropriate modalities for evaluating patients with weakness.
History
A 29-year-old male presents to the clinic with three-years of intermittent visual disturbances, difficulty walking, fatigue, and intermittent weakness in the right arm and leg. The symptoms seemed to improve somewhat in between but have generally been progressing. He had a transient loss of vision in his right eye one year ago that has since resolved. He has never sought medical attention for these symptoms before.
Physical Exam
BP 128/80, HR 90, RR 16, Temp 98.6F, O2 saturation 97% on room air.
Neurological examination shows decreased strength in the right upper and lower limbs (4+/5), increased tone, hyperreflexia, and a positive Babinski's sign on the right side.
Labs
None
Provisional Diagnosis
Select the Dx you believe is most appropriate
Based on the patient’s clinical presentation with several neurological deficits spread throughout space and time, relapsing-remitting multiple sclerosis is the most likely diagnosis.
Well done. You were correct
Potential Acuity
What is your assessment of the likely acuity for this patient?
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The patient should undergo urgent workup and management, as early treatment of active demyelination in multiple sclerosis may improve outcomes.
First Imaging Study
What is the first imaging study you will order?
The most appropriate imaging modality for the detection and quantitative assessment of lesions, as well as determining whether they are actively demyelinating, in the evaluation of suspected multiple sclerosis is a brain MRI.
Well done. You were correct
Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
Brain MRI without contrast
The lesions predominantly occupy:
These lesions are predominantly located in the periventricular regions.
Certain lesions are demonstrated as:
Several of these lesions are exhibiting enhancement on contrasted T1-weighted MRI, indicative of active demyelination.
View the full study if you'd like to take a look yourself.
Second Imaging Study
What is the next imaging study you will order?
No further imaging is required.
Well done. You were correct
What is your Diagnosis now that you have seen the imaging results?
The patient’s clinical presentation and imaging findings are strongly suggestive of multiple sclerosis.
Current Acuity
Initially, you selected and we suggested acuity.
Has your concern for this patient changed?
The patient should undergo urgent workup and management, as early treatment of active demyelination in multiple sclerosis may improve outcomes.
Assessment and Plan
Please provide your assessment and plan for this patient
The patient's presentation and MRI findings are consistent with the diagnosis of relapsing-remitting multiple sclerosis (MS). The presence of enhancement on the MRI suggests active disease progression. The patient should be referred to a neurologist for further management, including initiation of disease-modifying therapies (DMTs). Patient education regarding disease course, symptom management, and lifestyle modifications should be initiated. In the interim, we should administer high-dose corticosteroids this active episode with demyelination. A lumbar puncture should be considered to confirm the diagnosis.
Lessons Learned:
- Multiple Sclerosis is a chronic demyelinating disease. DMTs have been found to reduce the frequency and severity of disease relapses, slow disease progression, and improve the patient quality of life.
- The most common type of MS at disease onset is the relapsing-remitting type, which is characterized by intermittent episodes of worsening neurologic function, or relapses, followed by periods of partial or complete recovery, or remissions.
- The neurologic manifestations of MS are characteristically "distributed in space and time", implying that it impacts numerous regions of the central nervous system at different points in time.
- Plasmapheresis should be considered as a potential therapeutic strategy for patients with an MS flare that is resistant to corticosteroid therapy.
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