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
[date] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[patient name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[patient identifier number] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[date of birth] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. Use dd/mm/yyyy format. If age is explicitly stated, include after this item.)
[additional patient identifier] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Reason for Attendance:** [reason for attendance] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Diagnosis:** [document the patient's diagnosis including type and classification] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. Do not invent or infer a diagnosis.)
**Current Disease Modifying Treatment:** [current disease-modifying therapy including name and dosage] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Management Plan:**
[actions and referrals for professionals and patients listed in numbered order] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[treatment plan including disease-modifying therapy and administration details] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[pre-treatment tests and monitoring] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[multidisciplinary team involvement] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[follow-up imaging] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[recommendations for primary care physician] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[patient education and resources] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[follow-up plan] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[notifications to relevant authorities and organisations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[lifestyle recommendations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[review date] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Symptom Onset:** [symptom onset date] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Date of Diagnosis:** [date when the diagnosis was established] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Previous Disease Modifying Treatments:**
[previous disease-modifying therapy including name, duration, and reason for discontinuation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[additional previous disease-modifying therapy including name, duration, and reason for discontinuation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Other Diagnoses:**
[other relevant diagnosis stated by the clinician] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. Do not invent or infer a diagnosis.)
**Other Medications:**
[medication including name, dosage, and frequency] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. Write as a numbered list.)
**Actions for Primary Care Physician and Recommendations:**
[recommendation for primary care physician] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. Write as a list.)
**Assessment:** [description of current symptoms and relevant medical history] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. Do not invent or infer a diagnosis.)
[functional mobility measures] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
Past Medical History: [relevant past medical history] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
Smoking Status: [smoking status] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
Alcohol Intake: [alcohol consumption details] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
History of Vaccinations: [vaccination history] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[family planning, contraceptive methods, parity] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[medication allergies] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Related Symptoms**
**Vision:** [vision issues and interventions, advice, or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Balance and Coordination:** [balance and coordination issues and interventions, advice, or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Motor - Upper Limbs:** [upper limb issues and interventions, advice, or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Ambulatory - Lower Limbs and Mobility:** [lower limb and mobility issues and interventions, advice, or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Pain:** [pain issues and interventions, advice, or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Sensory:** [sensory issues and interventions, advice, or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Bladder:** [bladder issues and interventions, advice, or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Bowels:** [bowel issues and interventions, advice, or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Speech and Swallow:** [speech and swallow issues and interventions, advice, or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Cognition:** [cognitive issues and interventions, advice, or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Fatigue:** [fatigue issues and interventions, advice, or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Mood and Mental Health:** [discussions about mood, impact, coping strategies, other clinicians, medications, therapy and interventions, advice, or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Family Planning:** [contraception, family planning, pregnancy information] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Brain Health, Exercise, Smoking, and Diet:** [supplements, exercise, smoking, diet information and advice] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**On Neurological Examination:** [neurological examination findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Current Functional Assessment Score:** [functional assessment score value] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Current Symptom Assessment Score:** [symptom assessment score value] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Last Imaging:** [type of imaging] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[date of imaging] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[imaging findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[imaging requests] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Paraclinical Results:** [relevant laboratory results] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[date of results] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[context of results] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
**Discussion:** [analysis of the patient's diagnosis, symptoms, and imaging or laboratory results] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely. Do not invent or infer a diagnosis.)
[discussion of treatment options and patient's preferences] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[recommendations for additional management] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[clinician name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[clinician role or title] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[department or practice name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
[practice or hospital name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit completely.)
