Multiple Sclerosis

 

Thank you for asking to examine Harriet, who presented with difficult eye movements / difficulty walking / please examine the eyes / please examine the lower legs.

 

The most salient findings were eye, cerebellar, pyramidal and dorsal column deficits. The most likely unifying diagnosis is a demyelinating disease such as multiple sclerosis.

 

In further detail...

 

On general inspection, the patient was comfortable with nil apparent gait aids.

 

There was a waddling / broad-based ataxic gait with staggering to the left/right. The patient could/could not walk heel to toe, suggesting the presence/absence of a cerebellar pathology. The patient could/could not walk on their toes (S1), and the heels (foot drop, L4 or L5). Romberg’s sign was negative/positive. (eyes closed - posterior columns, eyes open - cerebellar).

 

On examination of the eyes, visual acuity was ___ on the right, and ___ on the left. There was a relative afferent pupil defect / there was a loss of direct reflex but intact consensual light reflex. Visual field testing revealed a central scotoma / was normal. Colour saturation was reduced / normal.

 

There was weakness of adduction in the right/left eye with nystagmus in the abducting eye, indicating right/left/bilateral internuclear ophthalmoplegia. There was/was not broken pursuit, and normal/hypometric/hypermetric saccades (hypo- is undershoot, hyper- is overshoot).

 

On fundoscopy, the optic disc is pale and has distinct margins, suggestive of optic atrophy.

 

The speech was slurred and a jerky, explosive, staccato character (ask to say Hippopotamus, Constitution, West Register Street).

 

L’Hermitte’s sign was negative/positive (flex the neck).

 

On examination of the arms, there was hypertonia and hyperreflexia, associated with pyramidal weakness.

 

There was impaired finger-nose testing with dysmetria and an intention tremor on the right/left side. There was dysdiadochokinesis. There was/was not rebound phenomenon in the arms.

 

On sensation, there impairment of vibration sense and proprioception in the hands.

 

Similarly, in the legs, there was hypertonia and hyperreflexia, associated with pyramidal weakness. There was ataxia, and impaired heel to shin testing. Vibration sense and proprioception were reduced.

 

In summary, the patient displays eye, cerebellar, pyramidal and dorsal columns, and multiple sclerosis is the most unifying cause.

 

Other differentials include:

• Other central demyelinating syndromes such as neuromyelitis optica, and acute disseminated encephalomyelitis (monophasic).

• Genetic causes such as - Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, usually called CADASIL

• Cerebellar and upper motor neuron signs - FA