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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Describe the signs and symptoms of multiple sclerosis (MS) that often mimic those of other neurologic diseases.

  • Design a pharmacotherapeutic regimen for treating an acute exacerbation of MS.

  • Identify patients for whom disease-modifying therapy (DMT) would be appropriate and recommend the most appropriate alternative for an individual patient.

  • Implement a pharmacotherapeutic plan for a patient with worsening MS.

  • Educate patients and health care practitioners on the proper dosing, self-administration (if appropriate), adverse effects, and storage of various medications used in MS.

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PATIENT PRESENTATION

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Chief Complaint

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“My legs are numb and weak, and I’m having trouble walking and urinating.”

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HPI

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Loretta Mansfield is a 26-year-old woman who was in excellent health until 4 days ago, when she developed numbness and tingling in her left foot. Over the course of the next 4 days, the numbness extended higher up her leg to her lower abdomen, stopping at the umbilicus, and then going down the right leg. She also developed weakness in both of her legs, is having trouble walking, and is bothered by urinary urgency.

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PMH

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Frequent migraine headaches since adolescence, that have been difficult to control despite therapy with acetaminophen, aspirin, and caffeine (Excedrin) and oral sumatriptan.

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Mild recurrent bouts of depression that have not been treated pharmacologically.

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Obesity most of her life.

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FH

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English descent. She was born in Arizona and moved at the age of 12 to Ohio. She has no siblings, and both parents are alive and well. There is no family history of neurologic disease.

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SH

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Married; employed as an accountant; smoked one pack per day for 8 years; use of alcohol is limited to an occasional glass of wine or beer on weekends.

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Meds

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  • Acetaminophen, aspirin, and caffeine (Excedrin) two tablets PO PRN headache

  • Sumatriptan 50 mg PO PRN migraine, at the onset of pain

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Allergies

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NKDA

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ROS

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Unremarkable except that she reports feeling run down and tired most of the day. No previous history of visual disturbance (eg, pain, blurred, or double vision), sensory, motor, bowel, bladder, or gait disturbance.

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Physical Examination

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Gen
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The patient is a Caucasian woman who appears to be slightly anxious but is otherwise in NAD

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VS
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BP 120/72 mm Hg, P 88 bpm and regular, RR 20, T 36.6°C; Wt 86.4 kg, Ht 5′2″, BMI 34.7

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Skin
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Normal turgor; no obvious lesions, tumors, or moles

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HEENT
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