a 52-year-old woman with tiredness and visual disturbance

yesterday rory presented an interesting case of a middle-aged woman, previously pretty well, who has become increasingly tired over recent weeks


she has also had some blurriness of vision


TIRED ALL THE TIME (TATT)


this is a common complaint but can sometimes be very difficult to diagnose


(also a common OSCE scenario)
_ _ _


i could not find a specific chapter in davidsons, harrisons or my favourite symptom book tutorials in differential diagnosis (written by eric beck who invented the MRCP exam & is still involved in PDS teaching at he whitt - i was his house officer many years ago; robert souhami was dean of UCL medical school)


in my library the best i could do was a case from an excellent MRCP book (case 2.50 in PACES for MRCP by tim hall)

however, i did find a BBC radio program all about TATT, part of the very good case notes series (with a full transcript available)
_ _ _


we discussed various causes:


- major organ failures (heart, kidneys, liver, lungs)
- endocrine disorders (thyroid, diabetes, also addisons, hypopit)
- cancer
- depression
- anaemia
- auto-immune type disorders (rheumatoid, lupus, GCA, polymyalgia)
- drugs, eg beta-blockers


our patient did not have any features pointing to the specific causes above?
_ _ _


we did not really go through investigations in detail
_ _ _


while we did not examine her, you did go through her pupillary reactions with gordon


she had an afferent pupillary defect [like this one?]

these data point to the possibility of multiple sclerosis

_ _ _

we briefly talked about this mostly relapsing-remitting condition

the diagnosis requires more than one 'attack' in more than one place

the criteria i learnt have now been replaced the the mcdonald criteria which incorporate the advances MRI has brought

rory was going to update us about MS [perhaps as a comment?]

we need to review her investigations, including MR imaging & LP

[tangentially, josiah bartlett, the fictional US president in the west wing, had MS & hid it from the electorate during his first election]

_ _ _

we finished by considering what we would do to learn more

reading a textbook & wikipeding were mentioned

find another patient with MS (soon) is a particularly good strategy

Salaam

sabih