A nurse is assessing a 32-year-old male client newly diagnosed with multiple sclerosis (MS). Which assessment finding would be most characteristic of early-stage relapsing-remitting multiple sclerosis?

Multiple sclerosis is a chronic, immune-mediated demyelinating disorder of the central nervous system. In the early stages of relapsing-remitting multiple sclerosis (RRMS), the pathological hallmark is the formation of focal inflammatory lesions in the white matter of the brain and spinal cord. These lesions disrupt the propagation of action potentials along axons, leading to transient neurological deficits that typically resolve partially or completely over weeks. This waxing and waning pattern is the defining feature of the RRMS phenotype and contrasts sharply with the progressive, irreversible disability accumulation seen in later disease stages.

The clinical presentation of an acute relapse depends entirely on the neuroanatomical location of the new demyelinating plaque. Common sites include the optic nerves, periventricular white matter, brainstem, and spinal cord. Because the inflammatory process is acute and focal, the resulting symptoms are sudden in onset and, critically, intermittent in nature during the early disease phase. This temporal pattern is a key distinguishing feature when evaluating a young adult with suspected MS.

Intermittent visual disturbances and fatigue is the most characteristic presentation of early RRMS.

• Intermittent visual disturbances: Optic neuritis is a classic and frequently the first clinical manifestation of MS. It presents with acute, typically unilateral vision loss, pain with eye movement, and desaturation of color perception. The symptom evolves over hours to days, stabilizes, and then gradually improves, exemplifying the "intermittent" pattern. The study on virtual reality-based oculography by Reuter et al. (2026) highlights the prevalence of subtle oculomotor dysfunction, such as internuclear ophthalmoplegia (INO), in MS. INO results from a lesion in the medial longitudinal fasciculus and causes diplopia or blurred vision on lateral gaze, which is another paroxysmal and intermittent visual symptom commonly elicited during assessment ^[2].


• Fatigue: This is one of the most common and disabling symptoms in early MS, often described as an overwhelming sense of exhaustion disproportionate to activity. The Poser et al. (2026) analysis of early disease course in a German MS cohort confirms that such symptoms are prominent in the initial presentation of therapy-naïve adults with RRMS ^[1]. Fatigue in MS is multifactorial, related to the underlying neuroinflammatory process, increased energy demands for neural conduction in demyelinated pathways, and sleep disruption.

The combination of these two symptoms—one reflecting a focal, relapsing neurological deficit and the other reflecting the diffuse impact of neuroinflammation—is highly suggestive of early RRMS.

• Option 1: Severe cognitive impairment and memory loss. While cognitive dysfunction, particularly in processing speed and memory, can occur even in early MS, it is typically subtle and not the "most characteristic" presenting finding. Severe, global cognitive impairment is more consistent with advanced or progressive disease stages, not the initial relapsing-remitting phase.


• Option 2: Bilateral lower extremity paralysis. This describes a severe, symmetric, and fixed motor deficit. In early RRMS, motor symptoms from a spinal cord lesion (e.g., transverse myelitis) are more likely to be unilateral or asymmetric and, crucially, are relapsing and remitting, not persistent and complete bilateral paralysis. This finding would be more suggestive of a spinal cord injury, a progressive form of MS, or another neurological condition.


• Option 3: Continuous muscle rigidity and tremors. The key word here is "continuous." Cerebellar and brainstem lesions in MS can cause tremors and spasticity, but in the early RRMS stage, these symptoms would manifest as part of a discrete relapse and would not be expected to be continuous and unremitting. Continuous, non-remitting symptoms are a hallmark of the secondary progressive phase of the disease.

When assessing a client with suspected MS, the nurse must interpret findings through the lens of the disease's temporal pattern. The Poser et al. (2026) study underscores that the initial presentation in RRMS is defined by discrete relapse events ^[1]. Therefore, a history of symptoms that appear, persist for a variable period, and then resolve is a critical diagnostic clue. The nurse's neurological assessment should specifically probe for these transient phenomena, including detailed history-taking about past episodes of visual changes, sensory disturbances (paresthesia), or unexplained fatigue that the patient may have dismissed. The use of advanced diagnostic tools, as explored by Reuter et al. (2026), demonstrates that even subtle, subclinical oculomotor findings like INO can be detected, reinforcing that visual pathway involvement is a core feature of the disease from its earliest stages ^[2].