Adele Spencer V5 PC
Interview
What are the events surrounding the start of your visual disturbances? When did your visual disturbance problem start?
Do you feel more fatigue/tired in the morning?
What treatments have
...
Adele Spencer V5 PC
Interview
What are the events surrounding the start of your visual disturbances? When did your visual disturbance problem start?
Do you feel more fatigue/tired in the morning?
What treatments have you had for your visual disturbances? How severe is your fatigue/tiredness?
How severe is your visual disturbances?
Does your fatigue/tiredness improve after a goodnight’s rest? Does your fatigue/tiredness come and go?
Do your visual disturbances come and go?
How quickly do your visual disturbances come on? Do you see any flashing lights?
Do you have any pain or other symptoms associated with your visual disturbances? Have you had visual disturbances like this before?
Do you become more weak or tired with exertion? Have you noticed blurred vision?
Any tingling or numbness in your arm(s)? Do you have double vision?
Any tingling or numbness in your hand (s)
Do you have any other symptoms or concerns we should discuss? Any problem moving your hand (s)?
Key Finding
Left optic disc pallor and edema :MSAP Dilated pupil on left: RELATED
Decreased left eye acuity (20/200): RELATED
Slow left pupillary response-afferent pupillary defect: RELATED Right upper extremity weakness: UNKNOWN
Right upper extremity diminished sensation: UNKNOWN Right upper extremity hyperreflexia: UNKNOWN Chronic non-productive cough: UNKNOWN
Repetitive occupational motion/stress arms bilaterally: UNKNOWN Fatigue: UNKNOWN
Resolved Diplopia (Double vision):RESOLVED
Systems Affected:
Cardiovascular, Neurological, Respiratory, Immune
Assessment
Vitals: BP, Temperature, Respiration, Pulse Neck: Auscultation carotid arteries HEENT: Test hearing
Chest wall & Lungs: Auscultation Heart: Auscultation
Neck: Auscultation carotid arteries Neurological: Plantar/Babinski (L5/S1) Diagnosis and Differential Diagnosis Diagnosis: Multiple Sclerosis
Differential: Brain neoplasm (Must Not Miss), Peripheral neuropathy (Must Not Miss), Vasculitis, Myelitis.
Diagnostic Test
MS TEST :Brain MRI, cervical spine MRI and CSF Brain neoplasm test : Brain MRI
Vasculitis : Anti-neutrophil cytoplasmic antibody (ANCA) Myelitis: Cervical spine MRI
Peripheral Neuropathy : Cervical spine MRI
Plan: Adele needs to be admitted and placed on MS treatment and follow up with neuro and physical therapy
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