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Med Surg Case Study #4

Presenting Complaint: A 30-year-old female patient presents to the clinic with complaints of intermittent numbness and weakness in her left leg, along with episodes of double vision that come and go. She also reports fatigue and difficulty with coordination, which have been progressively worsening over the past few months.


Patient Background: The patient, Ms. Anderson, has a significant medical history:

  • No significant prior medical conditions.

  • No known family history of neurological disorders.

  • She is an active individual who enjoys running and hiking.

  • She works as an office manager and reports increased stress levels recently.

Assessment:

  • Neurological examination reveals:

    • Decreased muscle strength in the left leg (4/5).

    • Numbness and tingling in the left leg.

    • Internuclear ophthalmoplegia (INO) on eye examination.

    • Hyperreflexia in the upper extremities.

    • A positive Babinski sign on the left side.


1. What are the possible diagnoses for Ms. Anderson's condition?


2. What diagnostics might be used to confirm the diagnosis?


3. What treatments might be needed for Ms. Anderson's condition?




See answers below





Med Surg Notebook








Answers

1. What are the possible diagnoses for Ms. Anderson's condition?

  • Possible diagnosis for Ms. Anderson's condition is multiple sclerosis (MS). MS is a common consideration due to her presenting symptoms, but other demyelinating disorders should also be ruled out.


2. What diagnostics might be used to confirm the diagnosis?

  • Diagnostics that might be used to confirm or rule out MS include:

    • Magnetic Resonance Imaging (MRI) of the brain and spinal cord to detect lesions and demyelination.

    • Cerebrospinal fluid analysis (CSF) to check for elevated levels of immunoglobulin G (IgG) or oligoclonal bands (proteins), which are indicative of MS.

    • Evoked potentials (e.g., visual evoked potentials) to assess nerve signal transmission.

3. What treatments might be needed for Ms. Anderson's condition?

  • If diagnosed with MS, treatments may include:

    • Disease-modifying therapies (DMTs) such as interferons or monoclonal antibodies to reduce relapses and slow disease progression.

    • Symptom management medications such as corticosteroids for acute exacerbations.

    • Physical therapy to improve strength and coordination.

    • Counseling or stress management strategies to address psychosocial aspects of the condition.





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