1. Practical Management of MS in the Primary Care Office Setting Case Study 2

2. Case 2: Diagnosis Presentation Ms. K, a 35-year-old woman, awakened with numbness in her right leg and thorax to level of sternum About 1 week later she developed numbness and tingling in her left hand After about 2 weeks the symptoms began to decrease in intensity She presented for neurologic evaluation about 6 weeks after onset; symptoms had almost entirely resolved

3. Case 2 History Ms. K reports that about 15 months prior to current symptoms she had developed a headache, poor depth perception, and balance difficulties A few days later she developed hearing loss in her right ear and right facial numbness She was evaluated by ENT who ordered brain MRI Neurologic symptoms resolved about 3 weeks after onset She was never told the MRI results

4. Case 2 Physical Examination General examination and mental status are normal Visual acuity: 20/20 both eyes Cranial nerves: subtle flattening of right nasolabial fold, otherwise normal Motor: 4/5 left hand intrinsics, otherwise 5/5 Sensory: decreased pain/temperature on left vs right –Vibration decreased bilateral great toe Coordination and gait: normal Reflexes: 1+ right upper extremity, 2+ left upper extremity, 4+ bilateral patellar, 3+ ankles, toes downgoing bilaterally

5. Case 2 MRI at Time of Second Event

6. Case 2 Discussion Questions 1.Does this patient meet McDonald criteria for MS? If not, what else is required? 2.What, if any, additional workup would you perform? 3.How would you counsel this patient? 4.Would you start treatment now?