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Case 1: Multiple Sclerosis
The Patient |
1. Start with the patient - a clinical
problem or question arises out of the care
of the patient. |
A 28-year-old woman presents with diplopia and imbalance. Past medical history is remarkable for migraine without aura and an unexplained 2-week episode of right monocular visual loss at age 22. Review of systems shows that for the past 2 months, she has experienced unusual fatigue, especially in the afternoon. She denies alcohol, tobacco, and recreational or prescription drug use. A maternal first cousin has MS. Physical examination shows pale optic disks, left internuclear ophthalmoplegia, wide-based gait with inability to perform tandem gait, and a left Babinski sign.
Brain MRI shows six white matter lesions. Four are periventricular and two of them enhance after administration of intravenous gadolinium. Visual evoked potentials show right conduction slowing compatible with an optic nerve lesion. CBC, chemistry group, RPR, sTSH, and ANA are within normal limits. A diagnosis of RRMS is confirmed using 2005 Revised McDonald Criteria, having shown multifocal central neurologic lesions disseminated in space and time.
After initial diagnosis, education, and counseling about MS and various forms of therapy, the patient initiated a five-day course of intravenous methylprednisolone to attempt to speed recovery from the current exacerbation. Her diplopia and imbalance resolved within 3 weeks, and at follow-up examination the only persistent abnormalities were optic disk pallor and the left Babinski sign. The patient elected to begin therapy with parenteral ß-interferon. Fifteen months later, she reported only intermittent fatigue and had experienced no new exacerbations. Repeated brain MRI showed one new brain lesion but no evidence of gadolinium enhancement.
The patient elected to continue interferon therapy but has heard from a relative that adding modafinil, every morning may reduce diurnal fatigue. A third year medical student working with the case has decided to research this possibility and report results to the patient's physician.
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The Question |
2. Construct a well-built clinical question
derived from the case. |
The Resource |
3. Launch DynaMed and
conduct a search using the well-built question from Answer A above. (Hint: In point-of-care databases it is best to start by searching for the pre-dominant medical condition, in this case "multiple sclerosis.") |
Based on your DynaMed search results please answer the following question.
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