Symptom Management Plan

Specialised Nurse **Management Plan Summary:** 1. Medication Changes: Gabapentin increased to 300mg three times daily. New prescription for Fluoxetine 20mg once daily initiated. Pending approval for Botox injections for chronic migraine. 2. Paraclinical Investigations: Referral for a comprehensive sleep study and an MRI of the brain to rule out structural causes for neurological symptoms. 3. Specialist Referrals: Referral to Neurology for further assessment of chronic migraine and peripheral neuropathy, and to Pain Management for interventional pain strategies. 4. Review Interval: Follow-up scheduled in 4 weeks for medication review and assessment of new symptoms. Subsequent review in 3 months with Neurology. **Diagnosis:** Chronic Migraine with Aura (G43.109), Peripheral Neuropathy (G62.9), and Generalised Anxiety Disorder (F41.1). **Current Disease Modifying Treatment:** Patient is currently on Topiramate 100mg twice daily for migraine prophylaxis, with good adherence reported. However, breakthrough migraines remain frequent. **Current Symptoms:** Primary reason for visit is persistent severe headaches and progressive numbness and tingling in the extremities. * **Headaches:** Patient reports daily headaches for the past 3 months, described as throbbing, unilateral, and associated with visual aura, photophobia, and phonophobia. Severity is rated 7/10 on average, significantly impacting her ability to work and perform daily tasks. * **Numbness and Tingling:** Gradual onset over the past 6 months, affecting both hands and feet symmetrically. Described as pins and needles, occasional burning sensation, worse at night. Impacting fine motor skills and balance. * **Anxiety:** Reports constant worry, difficulty concentrating, and restless sleep for the past year, exacerbated by chronic pain. **Functional Impact:** Symptoms significantly impair the patient's activities of daily living, including difficulty with self-care tasks (e.g., buttoning clothes), impaired mobility due to balance issues, and reduced work productivity due to headache severity and anxiety. Quality of life is significantly diminished. **Current Medications:** * Topiramate 100mg BID * Sumatriptan 50mg PRN for acute migraines (uses 2-3 times per week) * Paracetamol 500mg PRN * Ibuprofen 400mg PRN **Physical Examination:** Vital signs stable: BP 120/78 mmHg, HR 72 bpm, RR 16 bpm, Temp 36.8°C. Cranial nerves intact. Motor strength 4/5 in bilateral distal upper and lower extremities. Diminished sensation to light touch and pinprick in a stocking-glove distribution. Reflexes 1+ symmetrically in upper and lower extremities. Romberg's test negative, but gait is slightly unsteady with a widened base. Cognitive assessment reveals mild difficulty with concentration. **Assessment:** Patient presents with chronic, refractory migraines and progressive peripheral neuropathy, likely complicated by generalised anxiety. Symptoms are causing significant functional impairment and distress. The current management plan needs escalation and diversification to improve symptom control and quality of life. **Symptom Management Plan:** * Gabapentin 300mg three times daily (increased from 100mg BID) for neuropathic pain. * Fluoxetine 20mg once daily for generalised anxiety and potential neuropathic pain modulation. * Botox injections for chronic migraine (pending approval). **Specialist Referrals:** * Neurology for advanced migraine management and workup of peripheral neuropathy. * Pain Management Clinic for interventional pain strategies. **Patient Education:** Provided education on new medications (Gabapentin: potential for drowsiness; Fluoxetine: importance of consistent use, potential side effects). Discussed migraine triggers and non-pharmacological management strategies (stress reduction, sleep hygiene). Directed to the Migraine Trust website for additional resources and support groups. **Follow-up Plan:** Scheduled follow-up with the Specialised Nurse in 4 weeks (1 November 2024) to assess response to medication changes and ongoing symptom severity. Review of MRI and sleep study results will occur at this appointment. Patient encouraged to keep a headache diary.