MS Clinic

1 November 2024 Sarah Johnson PJN456789 05/03/1988 (Age 36) NHS_SJ88 **Reason for Attendance:** Follow-up appointment for ongoing Multiple Sclerosis management and assessment of current symptoms. **Diagnosis:** Multiple Sclerosis, Relapsing-Remitting Type (RRMS), confirmed in 2018. **Current Disease Modifying Treatment:** Ocrelizumab 300mg IV, last infusion 15/10/2024. **Management Plan:** 1. Liaise with Neurology Registrar regarding recent symptom fluctuation. 2. Refer to MS Physiotherapy for balance and gait assessment. 3. Provide patient with updated MS Society resources. Treatment plan including disease-modifying therapy and administration details: Continue Ocrelizumab infusions as per schedule (next due April 2025). Pre-treatment tests and monitoring: Routine blood work (FBC, LFTs, U&Es) to be completed 2 weeks prior to next infusion. Multidisciplinary team involvement: Continue regular reviews with MS Neurologist, Physiotherapist, Occupational Therapist, and Psychologist. Follow-up imaging: Schedule MRI brain and spinal cord for March 2025. Recommendations for primary care physician: Monitor for signs of infection, particularly UTIs, given bladder symptoms. Discuss Vitamin D supplementation. Patient education and resources: Provided information on fatigue management strategies and local MS support groups. Discussed importance of adherence to DMT. Follow-up plan: Review with MS Nurse in 3 months (February 2025) or sooner if symptoms worsen. Notifications to relevant authorities and organisations: None required at this time. Lifestyle recommendations: Encourage regular gentle exercise (e.g., swimming, walking). Advised on a balanced diet rich in fruits and vegetables. Review date: 1 February 2025 **Symptom Onset:** Approximately October 2017 (initial optic neuritis episode). **Date of Diagnosis:** June 2018 **Previous Disease Modifying Treatments:** Dimethyl Fumarate, 2 years, discontinued due to gastrointestinal side effects. **Other Diagnoses:** Migraine with aura. **Other Medications:** 1. Sumatriptan 50mg PRN for migraines. 2. Vitamin D3 1000 IU daily. **Actions for Primary Care Physician and Recommendations:** * Consider discussing prophylactic migraine treatment if frequency increases. * Reinforce importance of flu and COVID vaccinations. **Assessment:** Patient reports increased fatigue over the last month, impacting daily activities. Also notes mild worsening of balance, particularly in low light conditions. Denies new visual disturbances or motor weakness. EDSS score stable at 3.0. Well-groomed and alert, cooperative throughout assessment. Functional mobility measures: Timed 25-foot Walk (T25FW) performed in 8 seconds (previously 7 seconds 6 months ago). Single Leg Stance (SLS) 10 seconds right, 8 seconds left (previously 12/10 seconds). Past Medical History: None significant beyond MS and Migraine. Smoking Status: Never Smoker. Alcohol Intake: Occasional social drinking, 1-2 units per week. History of Vaccinations: Up to date with routine immunisations, including annual flu jab and COVID-19 boosters. Family planning, contraceptive methods, parity: Patient uses combined oral contraceptive pill. Parity 0. Medication allergies: Penicillin (rash). **Related Symptoms** **Vision:** No new visual complaints; previous optic neuritis resolved with residual mild blurriness in left eye. **Balance and Coordination:** Reports increased unsteadiness, particularly when turning quickly or walking on uneven surfaces. Referred to physiotherapy for assessment and balance exercises. **Motor - Upper Limbs:** No new weakness or dexterity issues reported. Fully independent with upper limb activities. **Ambulatory - Lower Limbs and Mobility:** Noted a slight increase in T25FW time. Ambulates independently with no aids, but reports mild difficulty with prolonged walking. **Pain:** Occasional neuropathic pain in feet, managed with gabapentin PRN. No acute pain exacerbation. **Sensory:** Reports mild pins and needles in both feet, constant but not interfering significantly with daily life. **Bladder:** Continues to experience urinary urgency and occasional incontinence. Uses absorbent pads daily. Referred to continence services for further assessment and management. **Bowels:** Reports mild constipation, managed with increased fluid intake and fibre. No recent changes. **Speech and Swallow:** No issues with speech or swallowing reported. **Cognition:** Reports mild subjective cognitive slowing, particularly with multitasking. Discussed strategies for managing 'brain fog'. **Fatigue:** Significant issue, rated 7/10 on fatigue scale. Discussed energy conservation techniques and importance of regular sleep schedule. **Mood and Mental Health:** Reports feeling a bit down due to increased fatigue, but denies significant depressive symptoms. Continues to see a psychologist for coping strategies. No new medication changes. **Family Planning:** No current plans for pregnancy. Discussed implications of MS medications on pregnancy if considered in the future. **Brain Health, Exercise, Smoking, and Diet:** Continues regular light exercise (walking 3 times a week). Consumes a balanced diet. Non-smoker. No specific supplements beyond Vitamin D. **On Neurological Examination:** Cranial nerves intact. Mild dysmetria on finger-to-nose testing bilaterally. Increased tone in lower limbs (Ashworth 1+). Deep tendon reflexes brisk, symmetrical. Planter responses flexor. Romberg test positive with eyes closed. Gait slightly ataxic. **Current Functional Assessment Score:** EDSS 3.0 **Current Symptom Assessment Score:** MS Impact Scale (MSIS-29) Physical: 55, Psychological: 40. **Last Imaging:** MRI Brain and Spinal Cord June 2024 Imaging findings: Stable number of T2 lesions in brain and spinal cord, no new enhancing lesions. No significant atrophy noted. Imaging requests: Repeat MRI Brain and Spinal Cord in March 2025. **Paraclinical Results:** Routine bloods (FBC, LFTs, U&Es) 25 October 2024 Context of results: All within normal limits, suitable for ongoing Ocrelizumab therapy. **Discussion:** Ms. Johnson presents for follow-up, reporting increased fatigue and mild worsening of balance. Clinical assessment aligns with reported symptoms, with objective findings of mild dysmetria and gait ataxia. Imaging remains stable with no new disease activity, which is reassuring. Discussion focused on symptom management strategies, referral to physiotherapy and continence services, and reinforcement of DMT adherence. Patient expressed understanding and agreement with the plan. Discussion of treatment options and patient's preferences: Patient is keen to continue Ocrelizumab due to good disease control. Expressed interest in exploring non-pharmacological interventions for fatigue and balance. Recommendations for additional management: Consider referral to occupational therapy for home assessment if balance continues to decline. Sarah Miller MS Specialist Nurse Neurology Department City General Hospital