Vickie is 37 years old and has been experiencing problems with numbness and tingling of her extremities, muscle weakness, clumsiness and has fallen several times over the past several months. When she had an episode of double vision, she consulted an ophthalmologist who found nothing on his exam that could explain the double vision. The ophthalmologist suggested that Vickie consult a neurologist

Vickie's past medical history is mostly unremarkable. She is currently on no prescription medications. She has two children; both pregnancies and deliveries were normal. As noted, she is having episodes of numbness and tingling of her limbs, clumsiness, double vision, difficulty walking on occasion. Her husband, who was present during the exam, noted that her speech had also been slurred on two different occasions.

An MRI of the brain, with and without contrast was ordered and Vickie and her husband are both here to discuss the finding. The MRI showed five different lesions, three of which were abutting the lateral ventricles. Lesions were also present in the posterior fossa. The results are indicative of multiple sclerosis. The MRI findings along with her clinical presentation confirm the diagnosis.

We discussed treatment option and the patient is being started on immunomodulating therapy. She is to return to the office in one month. She is to call if she has any questions before then or if she experiences any problems with the treatment regimen.

Dx: Relapsing/remitting MS

First-listed diagnosis: ________
Secondary diagnoses: ________
Fill in the blank with correct word.

First-listed diagnosis: ________
Answer: Relapsing/remitting MS – G35

Secondary diagnoses: ________
Answer: None