Question 4

Three years ago, he went to his primary care physician complaining of numbness on the left side of his face. The numbness was intermittent, and lasted for 3 months. A year later, he complained of tingling in his left upper extremity. This lasted for about 4 months. Six months, he developed double vision that lasted for 1 month.

**4a. What would be your PT Diagnosis?

4b. Any ideas about a medical diagnosis? What evidence supports your idea? What would need to be done to rule in or rule out your medical diagnosis?**

4a.For the PT diagnosis, I think it could possibly be peripheral neuropathy, and so the PT diagnosis could be, Pattern 5D: Impaired Motor Function and Sensory Integrity Associated With Nonprogressive Disorders of the Central Nervous System - Acquired in Adolescence or Adulthood. Peripheral neuropathy can be caused by many diseases, such as diabetes, lupus, underactive thyroid gland. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001619/ (Britt)

http://www.medicinenet.com/multiple_sclerosis/page3.htm

Any other ideas about a PT diagnosis? If the underlying medical diagnosis was one of the ideas below (MS, Tumor, cardiovascular), would that change your PT diagnosis? Is is also okay to have more than one PT diagnosis.

4b.A medical diagnosis would be MS. He has numbness and vision impairment which are common signs of MS. Complete or partial remission from symptoms occurs early in about 70% of individuals with MS. So, the beginning signs and symptoms that joe was having and the fact that they lasted only months and went away are also a common symptom of MS. (AMANDA)

4b. I agree with Amanda, I think that this patient could have a medical diagnosis of MS. Initial signs and symptoms for MS are first sensory symptoms, such as paresthesia-abnormal non-painful sensation in one extremity or head and face, visual blurring, and then diplopia-double vision. Based on Joe's presenting signs and symptoms I would suspect he could possible have MS. Infromation from Dr. Allan's Powerpoint- Physical and Electrical Properties of Cells in the Nervous System (Carley)

4b. I am in agreement with the MS diagnosis as possibility based on his symptoms. One thing that I have learned when researching MS in the past is that smoking can increase your risk of developing MS as well as increase your progression of MS. With Joe's past and current history of smoking, he could have increased his odds of developing MS. I thought this was an interesting fact and a different angle of looking at the diagnosis. (Megan)
http://www.nationalmssociety.org/about-multiple-sclerosis/what-we-know-about-ms/treatments/exacerbations/smoking-and-alcohol/index.aspx

Acute respiratory tract infection can lead to the onset of MS; smoking may be involved that way. (Erin)

I agree that MS is probably the medical diagnosis in this patient. This diagnosis seems to fit the symptoms best. However would it be necessary to rule out a brain tumor? Brain tumors can be a cause of numbness and tingling and can be cause double vision in patients. (Laura)
http://health.nytimes.com/health/guides/disease/brain-tumor-adults/overview.html

I agree with Laura. Though the symptoms seem to point to MS as a good clinician we would want to rule everything else out as well. It could be MS, it could be MS as well as another diagnosis, or it may not be MS at all. (Kelly)

The smartest thing to do is to rule out all all possibilities and so I agree with Kelly that there could be other possibilities. Many things can cause double vision and balance issues such as myasthenia gravis, MS, and brain tumors. (Denise)

I also agree, when I first looked at this I thought of brain tumors and MS. When the MRI is performed, that should be able to detect both conditions and give a more definitive answer. (Amber)

I agree that we need to rule out other possible causes as well. Do you think it would be beneficial to rule out cardiovascular issues? I know he is awefully young to have these issues and his symptoms are not necessarily acute, but angina is also presented in the left shoulder and down the arm to the fingers. Also senstation can be referred to the lower jaw and teeth. He doesn't have chest pain and his age makes it unlikely, but some of the symptoms are the same and his smoking habit puts him at a greater risk. I have heard of people having mini-stokes. Maybe something to look into?? (Chelsea) Interesting idea. You are right that he is not in the most likely age group, and he does not have associated symptoms such as chest pain. But he could potentially have small strokes, and the symptoms resolve as the nervous system adapts to injury.

What would cause double vision? Is it a problem in the visual system, or potentially somewhere else?

Double vision could be a result of muscle weakness within the eye and lack of coordination between the muscles. (Erin)

Uncontrolled diabetes may cause double vision. Although, diabetes doesn't seem to be a complete match for the other symptoms he is experiencing, I would still have him tested to rule it out. (Liz)
http://www.webmd.com/eye-health/double-vision-diplopia-causes-symptoms-diagnosis-treatment

Double vision could result from stroke. As it was mentioned earlier, he could possibly be suffering from mini-strokes and this in turn could be causing a majority of his symptoms. (Leslie)

His double vision could also be caused from a tumor that could be pressing on the optic nerve or another cranial nerve. (Sara)

QUESTIONS?

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