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.
Relevant History
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.
Allergies
No known drug allergies; no known food allergies.
Medications
None.
Physical Examination
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
1.
hat is the differential diagnosis?
2.
What is the most likely diagnosis? Why?
3.
Demonstrate your understanding of the pathophysiology in regard to the most likely diagnosis.
4.
Should tests/imaging studies be ordered? Which ones? Why? Think about tests/imaging beyond the primary care setting as well.
5.
What are the next appropriate steps in management?
6.
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.
Sample Solution
