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A 30-year-old woman presents to your office with a 2-day history of progressive, unilateral arm (proximal and distal) numbness without weakness. She has been diagnosed with fibromyalgia in the past. She is taking fluoxetine for depression and has a history of previous hospitalizations for depression. Which of the following is the most appropriate next step?
A) Monitor her symptoms and reassure her that her
numbness is likely related to her fibromyalgia.
B) Nerve conduction studies.
C) Head CT.
D) Ask about previous similar episodes or other neurological
concerns.
E) Chest radiograph and complete blood count.
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When she is asked about previous spells, she notes that she had an episode of left leg numbness that lasted about 1 week several years ago, but she thought nothing of it as it was mild. Six months ago she had a 3-day visual disturbance in her right eye, in which she found it difficult to read and focus on objects, but no blind spot was noticed. What is the most likely diagnosis based upon the history above?
A) Multiple sclerosis.
B) Fibromyalgia.
C) Conversion disorder.
D) Migraine.
If your patient indeed does have multiple sclerosis, which type is most likely?
A) Devic™s disease.
B) Relapsing-remitting.
C) Primary progressive.
D) B and C.
E) None of the above.
Which of the following tests would NOT be helpful in further diagnosing multiple sclerosis?
A) MRI of the brain.
B) Lumbar puncture.
C) Nerve conduction studies.
D) Visual evoked potentials.
Which of the following is NOT a recognized therapy for multiple sclerosis?
A) Corticosteroids.
B) Interferon-beta.
C) Glatiramer acetate.
D) Sulfasalazine.
E) Amantadine.
Which of the following treatments would you most likely choose for this patient, given her
history of depression?
A) Avonex (Interferon-beta 1A).
B) Amantadine.
C) Copaxone (glatiramer acetate).
D) Betaseron (Interferon-beta 1b).
Which of the following is associated with exacerbation of multiple sclerosis symptoms?
A) Cold temperatures.
B) Urinary tract infection.
C) Influenza vaccination.
D) Trauma.
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for 2nd set
1.A
2.B
3.B
4.E
5.C
6.A
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1-Discussion
The correct answer is D. This patient is experiencing
an exacerbation of her myasthenia gravis. This could
be occurring for any number of reasons, including
concurrent illness or possible noncompliance with her
regimen. The greatest morbidity and mortality for
this patient lie in the potential for respiratory failure
and arrest. In primary neuromuscular respiratory failure
(e.g., myasthenia gravis, acute inflammatory demyelinating
polyradiculoneuropathy, or Guillain-
Barré syndrome), the arterial blood gas may remain
normal despite impending respiratory collapse. The
best way to evaluate this is with the forced vital capacity
(FVC). If the FVC is 15 ml/kg, elective intubation
is recommended, although some centers will
choose to monitor these patients closely in an intensive
care setting without initial intubation. Monitoring
the FVC should be done regularly throughout
the hospital course until the patient is clinically
improved and stable.
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sorry guys I just posted the answer of the other case, I apologize !
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1-Discussion
The correct answer is D. Although ruling out other illnesses such as pneumonia may be important eventually, with the history of a progressive neurological deficit, the first step in the workup is to further explore the history. Frequently, patients will not include previous neurological symptoms because they are vague and the patient feels that they are not helpful, when in fact they can provide key clues to the diagnosis.
2-Discussion
The correct answer is A. Multiple sclerosis (MS) would be the most likely diagnosis based upon the history related above. MS frequently affects women of age 20“ 35 and men of age 35“45. It is almost 5 times more prevalent among women and is more common in the Caucasian population. MS is a central nervous system demyelinating disease of unknown etiology; it is thought to be an immune-mediated disease. The demyelinating lesions of MS occur in the deep white matter surrounding the ventricles and optic nerve, but can also occur in the cerebellum, brain stem, and spinal cord. The presenting symptoms of MS vary, but common symptoms are visual complaints, weakness, and sensory deficits. Although migraine can be associated
with neurologic symptoms, one would expect more stereotypic events and a history of previous headaches. Fibromyalgia is associated with numerous somatic complaints, but is not typically associated with sensory deficits or visual problems. Conversion disorder can produce all of the symptoms described above and is a diagnosis of exclusion.
3-Discussion
The correct answer is B. The two common forms of MS are primary progressive and relapsing-remitting. The diagnosis of relapsing-remitting MS is based on clinical grounds and laboratory data. Clinically, symptoms of CNS dysfunction develop over hours to days, stabilize, and then improve. It is important to identify clinical events disseminated in space and time. In this
case, your patient had a prior history of optic neuritis and lower extremity numbness and now has arm numbness. Answer A, Devic™s disease (neuromyelitis optica), is a central nervous system demyelinating illness that is characterized by bilateral optic neuritis, which may be simultaneous or may occur at different times, and spinal cord demyelination.
4-Discussion
The correct answer is C. Multiple sclerosis is a central demyelinating process and does not produce abnormalities that would be seen on nerve conduction studies. Answer A, an MRI, would obviously be helpful. Brain MRI is sensitive in detecting MS plaques with a frequency of 85“97% in definite MS cases. Multiple areas of increased signal in the periventricular area are
suggestive but not specific for MS. Gadoliniumenhancing lesions suggest active disease. T-1 weighted images appear as hypodensities (often referred to as œblack holes) and correlate with tissue destruction and disability. Answer B, an LP, can also be useful. CSF abnormalities suggestive of MS include oligoclonal bands and increased synthesis of IgG. A spinal fluid examination may be considered if the clinical diagnosis of MS is suspected but is not definite.
However, the positive and negative predictive value of CSF oligoclonal bands is inadequate to do more than support the clinical diagnosis. Recent evidence for serum antibody testing to other myelin components has yielded promising initial results as a supportive diagnostic tool. Finally, D, visual evoked potentials, may be helpful. Evoked potential may be used to aid in
the diagnosis of MS by indicating prior demyelination of the optic tract (optic neuritis) if the clinical history is vague (e.g., eye pain without vision loss or no recollection of symptoms). This will aid in proving the occurrence of separate events disseminated in space and time.
5-Discussion
The correct answer is D. Sulfasalazine is not useful in the treatment of multiple sclerosis. Immune modulating therapy reduces the number of exacerbations and active lesions on MRI. These include interferon-beta 1a (Avonex and Rebif) and interferon-beta 1b (Betaseron)
as well as glatiramer acetate (Copaxone). These medications are more efficacious if started early in the course of the disease. Common adverse affects of interferon include fatigue, depression, and myalgias. Amantadine is given commonly as monotherapy and in combination with immunomodulatory therapy to treat fatigue associated with multiple sclerosis. Corticosteroids have a role in treating severe acute exacerbations (e.g., optic neuritis, severe neurological impairments limiting activities of daily living) in the form of a short burst and taper (typically methylprednisolone 1 g per day, which may be in divided doses, for 3 days, followed by oral prednisone taper). Steroid use does not appear to offer long-term functional benefit, with the possible exception of regular pulsed steroid dosing. Currently, oral immunosuppressive
therapies (mycophenolate mofetil, azathioprine, and cyclosporin) are being considered in treating refractory multiple sclerosis, but their long-term efficacy and benefits are not known. Similarly, the value of IVIG and plasma exchange has not been conclusively demonstrated, and use of these treatment modalities is reserved for refractory patients.
6-Discussion
The correct answer is C. The interferon agents (Avonex, Rebif, and Betaseron) & amantadine are associated with worsening of depression. Given this patient™s history of severe depression requiring hospitalization, one would favor Copaxone as an initial therapy, although treatment with interferon is not absolutely contraindicated.
7-Discussion
The correct answer is B. Urinary tract infections can exacerbate multiple sclerosis. Systemic infection has been reported to provoke and/or mimic a multiple sclerosis exacerbation; urinary tract infections are particularly common secondary to neurogenic bladder as a result of chronic multiple sclerosis. Answer A is of special note. Cold is not associated with exacerbations,
but heat is notorious, and this phenomenon actually has a name”Uhthoff™s phenomenon. Answer C, vaccinations, including influenza vaccine, had been posited as a cause of exacerbations. However, a review of multiple clinical trials showed no increased risk of
exacerbations in patients with multiple sclerosis receiving the influenza, hepatitis B, or tetanus vaccinations. Note that we do not have experience with nasal influenza vaccine and multiple sclerosis. Since the nasal vaccine contains live virus, it should probably be avoided in patients with multiple sclerosis. Answer D, trauma, has been suggested as a possible exacerbation trigger, but the American Academy of Neurology clinical practice guidelines state that the majority of class II evidence available on this issue supports no connection.
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