Discussion 10: Case Study 6: The Nervous System
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Case Study #6a Neurologic System: Multiple Sclerosis Patient: Myrtle
Newly Diagnosed, (25 years old), Social History: Homeless, Unemployed, Single
Nonsmoker; no ETOH (ETOH is an acronym for ethyl alcohol); no illicit drugs
On line college student-struggles to understand material
RRMS (Relapse-Remitting Multiple Sclerosis)
2006: blurred & double vision
2013: Double vision; urinary urgency; poor attention
2012: Numbness in both legs
Diagnosis: RRMS – Relapse-Remitting Multiple Sclerosis
(2 episodes of neurological symptoms referable to the CNS, separated in space and in time)
Memory problems past 6 months; fatigue; heat intolerance; problems with balance
Prevalence by Cognitive Domains
Information Processing 35%
Problem Solving 20%
Visuospastial Abilities 20%
Verbal fluency 10%
Multiple domains (average)22%
Supporting the Diagnosis
Findings on exam:
–left INO internuclear ophthalmoplegia abbreviation: INO Loss of the normal paired movements of the eyes when tracking an object to the left or right. An INO is marked by the failure of one eye, e.g., the left, to cross the midline during an attempt to see an object on the opposite side of the body, e.g., the right.
–vertical nystagmus (a repetitive, involuntary, to-and-fro oscillation of the eyes. It may be physiological or pathological and may be congenital or acquired.), right ptosis,
–mild LE ataxia (the loss of full control of bodily movements) with tandem gait
MRI Brain and T spine
–Multiple enhancing white matter lesions
–High T2 signal in the right optic nerve
–Rim enhancing lesion at T6-7
–Bands notes in CSF and not in serum
IM Interferon beta-1a
Gabapentin 300mg tid
Oxybutynin Chloride 5mg tid
Multiple sclerosis (MS) is a progressive inflammatory disease of the central nervous system. It is the most common cause of neurologic disability in young adults, with onset generally occurring between ages 15 and 40 (In MS, local areas of the fatty material (myelin) that surround and insulate nerve fibers in the brain and spinal cord become inflamed and the myelin sheath is destroyed (demyelinated). This demyelination results in lesions (plaques or sclerosis) in the white matter (nerve cell tissue) of the brain, brain stem, optic nerves, and spinal cord, which can slow or block nerve impulse conduction. Production of these lesions has been observed by MRI studies to be fairly constant; 5 to 10 lesions may develop each year, corresponding to development of 1 or 2 new clinical signs or symptoms. MS is at least two to three times more common in women than in men, suggesting that hormones may also play a significant role in determining susceptibility to MS. And some recent studies have suggested that the female to male ratio may be as high as three or four to one.
DISCUSSION QUESTIONS Case Study #6a.
1•What is the effect of the demyelination on the nerves of an individual who has Multiple Sclerosis?
2•Why are the medications appropriate?
3•Why do you think females are at greater risk for MS?
Case Study #6b: Parkinson Disease
Ms. Smith is a 52-year-old woman presenting today with a chief complaint of a hand tremor that has worsened over the past three years. Her handwriting has become messy and sprawling and very difficult to read.. She shows signs of Rigidity, Bradykinesis and Postural Instability. Family history is positive for two grandparents both who had Parkinson’s disease. Medications include an antihypertensive, a statin, and an estrogen patch. Today her BP is 120/62. Height is 5’6”, weight 139 lbs. On physical examination, mental status, cranial nerves, sensation, muscle strength, tone, and deep tendon reflexes are all normal. There is a mild tremor bilaterally in both hands as she writes her name. No tremor at rest. Voice is somewhat tremulous. There is a slight involuntary back-and-forth horizontal rotation of the head.
Lab data, including lipids, TSH and FBS are all within normal limits.
Discussion Question for Case Study #6b:
What is Parkinson Disease?
Hint: Parkinson’s disease:a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people.
It is associated with degeneration of the basal ganglia of the brain and a deficiency of the neurotransmitter dopamine.
What are the symptoms of Parkinson Disease?
Hint: Tremor or Shaking, Rigidity, Bradykinesis, Loss of Smell, Trouble Sleeping, Trouble Moving or Walking, Constipation, A Soft or Low Voice, Stern Face Appearance, Dizziness or Fainting, Depression and Stooping or Hunching Over Posture.
What are the effective treatments of Parkinson Disease?
Hint: A combination of Medications to enhance the release or supply of dopanmine (DA): Levodopa, Carbidopa, Sinemet, and Anticholinergics as well as as Monamine Oxidase (MAO) Inhitor and Catechol-O-Methyl Transferase (COMT) Inhibitor are frequently prescribed and have shown to be effective in reducing the symptoms of Parkinson Disease, but there is no cure!
Deep Brain Stimulation (DBS) has shown to be helpful but is not without risk!