1. Step 8
1.1. Diagnostic decision
1.1.1. MS
1.2. Mechanism
1.2.1. multifactorial .. inflammation that targets the CNS mylien sheath
1.3. Presentation
1.3.1. left homonyms heminopia
1.4. Supporting data
1.4.1. history of urinary incontinance and walking difficulty a year ago
1.4.2. MRI
1.4.3. CSF
1.4.4. exclusion for other possible diseases
1.5. 10 minutes
2. Step 6
2.1. Review session 1
2.2. Report new knowledge
2.2.1. mylien sheath
2.2.1.1. physiology
2.2.1.1.1. proteolipid sheath that surround the axons to speeds the conduction of the electrical impulse .. they leave gaps of unmylinated axons called nodes Ranvier
2.2.1.1.2. the function of the action potential will be reduced from 5-10
2.2.1.2. pathophysiology
2.2.1.2.1. dysmylinating disease
2.2.1.2.2. destruction of the mylin
2.2.2. MS
2.2.2.1. causes
2.2.2.1.1. mysterious diseases .. multifactorial
2.2.2.1.2. genetic and environmental factors predispose
2.2.2.2. symptoms and sign
2.2.2.3. diagnosis
2.2.2.3.1. criteria are usually used for the classifications purposes not and researchs
2.2.2.4. epidemiology
2.3. 30 minutes
2.3.1. The scribe does not have to write in this step!
3. Step 7
3.1. Inquiry plan and info gathering
3.1.1. History of presenting complain
3.1.1.1. started 2 wks ago
3.1.1.2. the first time to have such attack
3.1.1.3. 2 days ago hit a child in the stairs
3.1.1.4. "not noticing things in hrer left side"
3.1.2. Previous medical / surgical history
3.1.2.1. urinary incontinence and walking problem
3.1.2.1.1. 3 wks of uncoordinated movement with urinary incontinence one year ago
3.1.2.1.2. unsteadiness gait
3.1.2.1.3. antibiotics were prescribed
3.1.2.1.4. 8 yrs ago was diagnosed with myopia
3.1.3. Drug history / allergy
3.1.3.1. no allergies
3.1.3.2. previously used antibiotics
3.1.3.3. Oral contraceptive
3.1.4. Family history
3.1.4.1. clear family history
3.1.5. Social / occupational history
3.1.5.1. pediatric residence
3.1.5.2. lives in saudi arabia moved from Kuwit
3.1.5.3. not smoker or alcoholic
3.1.5.4. she is married since one year .. no children
3.1.6. Systemic review
3.1.7. Physical examination
3.1.7.1. normal vitals
3.1.7.2. normal mental
3.1.7.3. confrontetional test showed left homonomus heminopiia
3.1.7.4. normal visual acuity
3.1.7.5. normal color
3.1.7.6. no retnal abnormality
3.1.7.7. cranial nerves all normal
3.1.7.8. carotid artery pulse are normal
3.1.7.9. other systems are normal
3.1.8. tests results
3.1.8.1. MRI
3.1.8.1.1. a large area of confluent increase signal intensity on axial T2 weighted images in optic radiation especially in the right
3.1.8.1.2. numerous punctate areas in weighted images in optic radiation in the white matter of the periventricular area temporal or occiptital horn
3.1.8.2. CBC
3.1.8.2.1. normal
3.1.8.2.2. ESR not elevated
3.1.8.3. CSF
3.1.8.3.1. 20 WBC per mm2
3.1.8.3.2. 94% are lymphocytes
3.1.8.3.3. normal protein and sugar with increased IgG index oligoclonal banding
3.1.8.4. visual evoked potential
3.1.8.4.1. left abnormalities