A 32-year-old otherwise healthy woman presents to her PCP complaining of blurred vision, light-headedness, diplopia, and numbness in her lower extremities, tongue, and left side of her face. The symptoms became increasingly worse over a period of 2 months and then began to improve, with complete resolution of symptoms by the fourth month. The patient reported no relieving or aggravating factors while the symptoms were present.
Review of Systems
A ROS is positive for rash to anterior chest; occasional headache; double vision; blurred vision; numbness in lower extremities, tongue, and left side of face; and anxiety related to current symptoms. The ROS is negative for weight change, hearing loss, tinnitus, epistaxis, SOB, chest pain, cough, nausea, vomiting, diarrhea, abdominal pain, urinary symptoms, bruising, or temperature intolerance.
The patient’s medical history is significant for measles at the age of 9 months and infectious mononucleosis at the age of 20. She wears glasses and contacts. Her family history is significant for hypertension in mother and father; her maternal grandfather has chronic renal failure. Her social history includes a 15-pack-year history of tobacco use, no alcohol, no illicit drug use. She lives with her husband and their golden retriever.
No known drug allergies; no known food allergies.
Vitals: T 37.2°C (99.0°F), P 92, R 16, BP 122/72, WT 61.70 kg (136 lbs), HT 167.64 cm (66 in.), BMI 22.
General: Healthy appearing, well-dressed, well-groomed female in no apparent distress.
Skin, Hair, and Nails: Small and erythematous papules on the anterior chest under bilateral breasts. No abnormal findings with hair or nails.
Head: Atraumatic, normocephalic.
Eyes: EOM reveals a sixth nerve palsy of the left eye, decreased visual acuity of the right eye (OD 20/40) with an enlarged cup/disc ratio; PERRL.
Lungs: CTA bilaterally.
Heart: RRR; no murmurs, rubs, or gallops.
Lymphatic: No lymphadenopathy noted.
Neurologic: Positive Lhermitte sign; decreased sensation to L2 to L5 and S1 of lower extremities; DTR of bilateral lower extremities 1+ with decreased sensation of tongue and of the ophthalmic nerve distribution of the left side of the face.
Clinical Discussion Questions
hat is the differential diagnosis?
What is the most likely diagnosis? Why?
Demonstrate your understanding of the pathophysiology in regard to the most likely diagnosis.
Should tests/imaging studies be ordered? Which ones? Why? Think about tests/imaging beyond the primary care setting as well.
What are the next appropriate steps in management?
Review a recent and credible research article(s) about this diagnosis. Demonstrate your understanding of the diagnostic criteria, risk factors, and treatment options. Include a list of your reference(s).
- What are the pertinent ICD-10 and CPT (E/M) codes for this visit. Provide a short rationale.
Lifetimes of experience have shown us the truth of human fallibility-what one believes to be true at one moment may in time prove false. One mistaken opinion can give rise to countless others, and as a result, certainty itself is in fact, rarely certain. In his Meditations on First Philosophy, René Descartes takes note of this, realizing that "if [he] wanted to establish anything firm and lasting in the sciences" (Meditations 59), he must first establish a basis of truth and certainty. In order to ascertain such a foundation, however, he must first determine what he can be certain of and what he cannot, and so, to root out his false opinions, Descartes seeks a reason to call his current beliefs into doubt. In the first of his Meditations, he addresses several such reasons in the form of hypothetical situations. One of the more significant of these theories, the possibility that he is dreaming, he determines to be ultimately ineffectual and, as a result, eventually raises the possibility that some omnipotent evil exists with the sole function of deceiving him. As mentioned previously, Descartes finds a need to call all his opinions into doubt, yet he realizes that to disprove each and every belief on its own would be an impossible task. He resolves, therefore, to strike at the most fundamental of his opinions, reasoning that this will debase all other beliefs and remove the necessity of invalidating them individually. With this in mind, he then makes note of the fact that "whatever [he] had admitted until now as most true [he] received either from the senses or through the senses" (60) which he also notes are "sometimes deceptive" (60). However, this deception of the senses applies only to "very small and distant things" (60), Descartes clarifies, pointing out that there remain many matters similarly derived from the senses that cannot be doubted, his presence in a chair by the fire and the paper in his hand, for example. Thus, in itself, the senses' ability to deceive does little to destabilize Des-cartes' beliefs at all and so hardly aids him, but the concept serves as an impetus for another line of inquiry. "On what grounds," he asks, "could one deny that these hands and this body are mine?" (60), and in response to this, he presents two hypothetical situations, both of which would allow him to doubt the truth of reality. While his first theory, that he could be insane, would certainly raise within him doubts about reality, he ultimately rejects it, as assuming himself insane would destroy the credibility of his entire argument. This idea does, however, lead to a second and more effectual scenario, a hypothesis in which he considers the possibility that he is dreaming. While this second theory seems to hold considerably more efficacy than the previous one, Des-cartes still finds reason to discard it. Before this reason can be addressed though, the nature of the hypothesis must be noted: Descartes observes that "often does [his] evening slumber per-suade [him] of such ordinary things as [this]: that [he is] here . . . seated next to the fireplace-when in fact [he is] lying undressed in bed" (60). Upon further contemplation, he recalls encoun-tering other such deceptions in his dreams and eventually concludes that "there are no distinctive signs by which to distinguish being awake from being asleep" (60). With this inability to diffe-rentiate between dream and reality in mind, Descartes assumes for his argument's sake that he is dreaming, which seems to cast doubt on both reality en masse and on all opinions that arise from it. Yet Descartes continues to delve, and in so doing, he discovers that while composite reality can be doubted, those things that comprise it, its individual components, cannot. He notes that "the things seen during slumber . . . could only have been produced in the likeness of true things" (61) and therefore "are true and exist" (61). Similarly, he recognizes that although it is possible for such "composite things" (61) to be imaginary, it is also possible to divide them into simpler and more universal components that are not im>GET ANSWER