Case study

Linda Hutchison, a 49-year-old Caucasian high school teacher, has had multiple sclerosis (MS) for
over 20 years. She has been very tired lately, has had trouble maintaining urinary continence, is
experiencing weakness, and describes a pins and needles feeling in her legs. Also, muscle
spasms at night are affecting her ability to sleep. She is concerned about an exacerbation of her MS
and arrives at her scheduled appointment to discuss ways to prevent this from happening.
Biographical Data:
LH, 49-year-old Caucasian woman. Alert and oriented. Asks and answers
questions appropriately. Had been working as an office manager at the local high school, but recently
began teaching (her first love) language classes (French and German); she is also responsible for
teaching two physical education (PE) classes a week.
Reason for Seeking Health Care:
I have been so tired and weak lately, and have been having trouble with urinary continence and a
pins and needles feeling in my legs. Leg spasms at night are keeping me awake. I am anxious that I
will have an exacerbation of my MS.
History of Present Health Concern:
The current symptoms began after she recently changed jobs. I get so tired by the end of the week.
If I rest all weekend, I am OK by Monday morning. Ms. Hutchison has had MS for 20 years, but
has managed to function at a near-normal level for most of that time. I had one severe exacerbation
during my divorce, but I went into remission after about 6 months.
Ms. Hutchison denies numbness, seizures, or dizziness. She has not noticed a change in sensations of
taste or smell, hearing, or vision. Client denies difficulty speaking or swallowing. She denies loss
of bowel control. Client denies recent or remote memory loss.
Personal Health History:
Client denies head injury, meningitis, encephalitis, spinal cord injury, stroke or any treatments.
Family History:
Ms. Hutchison reports that her mother has hypertension and migraine headaches. Her father and 2
sisters are in excellent health. Maternal grandmother has hypertension and obesity. Maternal
grandfather died as a result of an automobile accident at age 35. Paternal grandmother has
rheumatoid arthritis. Paternal grandfather has coronary artery disease, hypertension, and diabetes
type 2. Ms. Hutchinson denies a family history of cerebrovascular disease, epilepsy, brain cancer, or
Huntingtons chorea.
Lifestyle and Health Practices:
Takes oxybutynin (Ditropan) as prescribed for MS. Takes multivitamin daily. Denies use of tobacco
or recreational drugs. Reports drinking 23 glasses of wine every 23 months. Reports wearing a
seatbelt at all times. Denies participation in any activities requiring protective headgear. 24-hour
diet recall: Breakfastcereal with 2% milk and 1 cup of coffee; lunchplain ham and cheese
sandwich, 1 small bag plain potato chips, and an apple, with unsweetened iced tea; dinnerpetite
filet mignon, loaded baked potato, salad, water. Denies exposure to lead, insecticides, pollutants, or
other chemicals. Denies frequent heavy lifting or repetitive motions. Reports that she is able to
perform ADLs independently. Denies any change in self-esteem or body image.
Physical Exam Findings:
Alert, thin, middle-aged woman with mildly elevated blood pressure and pulse rate (136/92 and 98).
According to her chart, Ms. Hutchisons blood pressure is normally 100/70.

CN I: Able to correctly identify scents bilaterally.

CN II: Vision 20/20 right eye, left eye, and both eyes. Visual fields intact. Red reflex present
bilaterally. No other internal structures visualized by examiner.
CN III, IV, VI: Extraocular movements intact. No ptosis noted bilaterally. Pupils 5 mm, constricting
to 3 mm bilaterally. Pupils reactive to light and accommodation.
CN V: Temporal and masseter muscles contract bilaterally. Able to identify light touch to forehead,
cheek, and chin. Corneal light reflex symmetric.
CN VII: Able to smile, frown, wrinkle forehead, show teeth, puff out cheeks, purse lips, raise
eyebrows, and close eyes against resistance.
CN VIII: Able to hear whispers from 3 feet bilaterally. Weber test with equal lateralization. Rinne test
AC > BC.
CN IX, X: Uvula and soft palate rise symmetrically with phonation. Gag reflex present. Swallows
without difficulty.
CN XI: Equal shoulder shrug with resistance bilaterally. Turns head in both directions with
resistance.
CN XII: Tongue midline without tremor. Strength of tongue intact.
Motor function:
Muscles are fully developed and symmetric in size.
All muscle are equally strong against resistance. Full range of motion of all extremities.
No involuntary movements noted.
Gait is steady with opposite arm swings. Maintains balance with tandem walking.
Romberg sign is negative.
Rapid alternating movements, finger-to-nose movements and heel-to-shin movement smooth and
intact.
Sensory:
Identifies light, sharp, and dull sensation to extremities and trunk.
Vibratory sensation, sensitivity to position, and stereognosis are intact.
Reflexes:
brachioradialis, bicep, triceps, patellar and achilles reflexes 2+ bilaterally with no ankle clonus.
Abdominal reflex present. Plantar reflex with toe flexion.
No signs of meningeal irritation or inflammation.