top of page

Multiple Sclerosis

Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓

 

Doctor Instruction:


You are a doctor working in family medicine. You have a 34-year-old woman, Sakura Haruno, presenting with numbness + tingling sensation affecting both hands and feet. Please take a history and perform an appropriate examination.



 

Patient History:


Sakura Haruno - a 34-year-old female - product manager in a health tech company.


You noticed tingling + numbness affecting both your hands and feet 2 weeks ago. You still have these symptoms– however, you think the symptoms are improving slightly recently. You have also noticed weakness affecting both your hands and feet. You recently had a COVID vaccination one week before developing these symptoms - you are not sure if this is related as you heard many stories about the side effects of the vaccination. You also felt sick after having the vaccination with flu-like symptoms for a few days.


Nowadays you also feel really tired – wanting to sleep more than usual. You don't feel like your usual self – always forgetting things. You have found yourself quite unsteady sometimes. Because of this, you had a few falls at home. Luckily you didn't hit your head. You just want to get better.


No incontinence/pain/Lhermitte’s sign/balance issues/weight loss/fever/problems with waterwork or bowel movement.


Mention only if asked: You remember having a problem with your right eye 5 months ago, and you remember having pain moving your eyes, a problem with vision and a bit of double vision. You can't remember much about this.


Ideas, Concerns, Expectations:

  • You think it is related to your COVID vaccination, and you are worried that you might also get blood clots from the vaccination, which can cause a stroke! Ask if this is true. You want to find out what is going on and see if you can have any blood thinners.


Past Medical History:

  • Obesity

  • Coeliac Disease

  • Hypertension


Drug History:

  • Atorvastatin

  • Rampiril

  • NKDA


Family History:

  • Mum has SLE.

  • Dad developed a stroke at the age of 50.


Social History:

  • You are a smoker who smokes 10 cigarettes/day for 3 years

  • Drink 2 cans of lager every night

  • Occupation: Product Manager in Healthtech

  • Managing well at home, living with a partner.


 

Examination Findings:

  • Weakness affecting both feet and hands

  • Spasticity/Increased muscle tone in the legs

  • Broad-based gait

  • Sensory ataxia – Romberg’s test positive


 

Differentials:

  1. Multiple Sclerosis (symptoms/signs + history of optic neuritis)

  2. Vitamin B12 Deficiency - Tiredness + coeliac disease + neurological signs

  3. Guillain Barre Syndrome - Possible flu before symptoms, vaccination association, but would be primarily motor neuron dysfunction


 

Investigations:


Bedside:

  • Basic Observations

  • Capillary Glucose - assess for Hypoglycaemia as a cause of neurological symptoms


Bloods:

  • Baseline bloods – FBC/U&E/ LFTs/ CRP

  • FBC – may show macrocytic anaemia in B12 deficiency

  • LFTs – elevated AST + ALP in GBS

  • FBC – may show macrocytic anaemia in B12 deficiency

  • Vitamin B12 - low in B12 deficiency

  • Anti-ganglioside antibodies – may be positive in GBS


Imaging:

  • Fluid Attenuated Inversion Recovery (FLAIR) MRI of the brain and spinal cord to look for demyelinating lesions.


Special Tests:

  • Lumbar Puncture

    • oligoclonal bands & raised IgG in CSF in MS

    • elevated CSF protein in Guillain-Barre syndrome

  • Nerve conduction studies – slow nerve conduction velocity in GBS

  • Spirometry – reduced vital capacity in GBS


 

Data Interpretation:

        Want to read more?

        Subscribe to oscefinals.com to keep reading this exclusive post.

        bottom of page