A 32-year-old woman comes to the office with several days of tingling and numbness in both hands. She moved to Arizona in June to care for her ailing mother who died 2 weeks ago of metastatic lung cancer. Since moving, she has had occasional headaches, dizziness, fatigue, poor sleep, and blurry vision. She has had no fevers, weight loss, or anorexia. Her medical history is unremarkable. The patient drinks 1 or 2 glasses of wine daily but does not use tobacco or illicit drugs. Her blood pressure is 132/70 mm Hg and pulse is 78/min. Sensation to light touch and pain is decreased distally in the bilateral upper extremities. Muscle strength is 5/5 in the upper and lower extremities and deep tendon reflexes are normal. On funduscopic examination, the right optic disc appears hyperemic and swollen. Which of the following is the best next step in management of this patient?

Question

A 32-year-old woman comes to the office with several days of tingling and numbness in both hands.  She moved to Arizona in June to care for her ailing mother who died 2 weeks ago of metastatic lung cancer.  Since moving, she has had occasional headaches, dizziness, fatigue, poor sleep, and blurry vision.  She has had no fevers, weight loss, or anorexia.  Her medical history is unremarkable.  The patient drinks 1 or 2 glasses of wine daily but does not use tobacco or illicit drugs.  Her blood pressure is 132/70 mm Hg and pulse is 78/min.  Sensation to light touch and pain is decreased distally in the bilateral upper extremities.  Muscle strength is 5/5 in the upper and lower extremities and deep tendon reflexes are normal.  On funduscopic examination, the right optic disc appears hyperemic and swollen.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d487_81b9_bc81_0bf3f0125952_MD0003_00 This patient likely has multiple sclerosis (MS), an autoimmune inflammatory demyelinating disorder of the central nervous system (CNS) that typically presents with neurologic deficits disseminated in space and time (eg, sensory loss/paresthesias of the extremities, dizziness, optic neuritis) in women age 15-50. Symptoms may worsen during exposure to high temperatures, such as moving to Arizona in June (Uhthoff phenomenon). When MS is suspected, magnetic resonance imaging (MRI) of the brain and spine is typically performed to support the diagnosis. T2-weighted imaging usually demonstrates multifocal, ovoid, subcortical hypo-/hyperintense lesions located in the white matter of the CNS, particularly the periventricular and subpial white matter of the cerebrum (corpus callosum), optic nerves, brainstem, and spinal cord. Lumbar puncture can be performed after an MRI to document oligoclonal IgG bands in the cerebrospinal fluid (found in 85%-95% of patients with MS), especially in cases in which the diagnosis is not clear (Choices C and F). magnetic resonance imaging (MRI) (Choice A) Carotid Doppler ultrasound is usually performed to evaluate for atherosclerotic plaques in patients with stroke, which typically presents with acute-onset, focal neurologic deficits; however, stroke is unlikely in this young patient with no cardiovascular risk factors. (Choice B) Cervical spine x-ray may be considered when there is concern for cervical spine disease (eg, spinal or neuroforaminal stenosis). Patients generally present with neck pain and can have bilateral hand/arm numbness and weakness; however, Uhthoff phenomenon and optic neuritis are not characteristic. (Choice E) Nerve conduction studies are helpful in diagnosing peripheral nervous system disorders (eg, entrapment neuropathies, polyneuropathies, radiculopathies); however, they are not typically used in the diagnosis of CNS disorders such as MS. (Choice G) Benzodiazepines (eg, lorazepam) may be considered in the treatment of anxiety and insomnia but would not help in the diagnosis of the underlying condition. This patient's symptoms cannot be attributed to a psychiatric illness without first ruling out medical causes. Educational objective: When multiple sclerosis is suspected, magnetic resonance imaging should be performed to support the diagnosis. T2-weighted imaging usually demonstrates multifocal, ovoid, subcortical white matter lesions located in periventricular, juxtacortical, infratentorial, or spinal cord areas. References: MR imaging of multiple sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/21602503)

A 32-Year-Old Woman Comes to the Office with Several Days