The History of Illness

What is the CC in this Case Study?

A patient presented the chief complaint of bodily fatigue, twitch, and a possibility of fainting during some physical exercises. Besides, this disease might also influence weakness in one’s legs and constantly blurred vision. Moreover, it is essential to accent on infections that affected the patient’s urinary tract.

What are the important questions to ask the patient to formulate the history of present illness and what did the patient tell you?

The primary purpose of the patient’s medical history is to provide a doctor or a nurse with an accurate description of one’s chief complaint and other problems that might refer to the treatment process. However, it is essential to ask various questions and discuss a remaining problem with a patient to make a precise conclusion for a future diagnosis, which will be formulated in his or her medical history (National Multiple Sclerosis Society, 2017). The following paragraph is to provide some instrumental questions:

  • Why do you need medical care? I was tired during the last six months – some days were fine, but some were unbearable. I also feel needles in my body.
  • What did you do to provoke your symptoms? I do not remember.
  • Do you feel better when you rest? No, but it gets worse when I am doing any kind of physical activity.

What components of the physical exam are important to review in this case? What are the pertinent positive and negative physical exam findings to help you formulate your diagnosis?

A physical examination is essential to be as accurate as possible for proper identification of the patient’s diagnosis. This particular case requires making an MRI of the patient’s brain, whereas the lumbar spine might help show if any changes occurred. Such laboratory tests as B12, BMP, CBC, are also required in this case (Woo & Wynne, 2011). Moreover, it would be proper to run a UA C&S to identify if there are any issues in the urinary system.

As all the cases of multiple sclerosis are tough to diagnose, it would be advantageous to examine the results of analyses and to make a physical examination of a patient. One of the main positive findings was the result of MRI, which showed demyelination by white matter T2. Besides, positive oligoclonal bands were found with the help of cerebrospinal fluid examination. Nevertheless, the patient sometimes could not move her legs after waking up in the mornings, which made it difficult to diagnose as multiple sclerosis.

Which differential diagnosis is to be considered with this case study? What was your final diagnosis?

Several differential diagnoses might also be considered with this case study. The following presumptions were made due to the analysis and physical examination of the patient. Therefore, Schilder disease, sarcoidosis, vasculitis, and Lou Gehrig’s disease were identified as differential diagnoses. Besides, there is a possibility of such diseases as transverse myelitis, and spinal cord neoplasm.

After comparing and studying all the symptoms, I identified the final diagnosis of multiple sclerosis. The main reason for this conclusion was the fact of affected myelin sheaths, which was evident after the MRI analysis. Unfortunately, I could not make the patient aware of the primary reason that caused this disease. Moreover, some genetic and environmental factors were also considered, which helped in establishing the aforementioned diagnosis.

References

National Multiple Sclerosis Society. (2017) What causes MS?. Web.

Woo, T. M., & Wynne, A. L. (2011). Pharmacotherapeutics for nurse practitioner prescribers (3rd ed.). Philadelphia, PA: F. A. Davis Company. Web.