Home Visit

Specialised Nurse Home Visit Note **Management Plan:** 1. Referral to Occupational Therapy for home safety assessment and recommendations for adaptive equipment. 2. Scheduled follow-up home visit in 4 weeks to review progress and medication adherence. 3. Patient to continue daily exercises as prescribed by physiotherapist. 4. Education provided on symptom management strategies and warning signs for relapse, including when to contact the clinic. **Reason for Home Visit:** Comprehensive assessment of patient's current functional status, home environment, and adherence to disease-modifying therapy following a recent exacerbation. **Patient Concerns:** Increased fatigue, difficulty with ambulation particularly on stairs, and concerns regarding managing medication schedule independently. **Diagnosis:** Multiple Sclerosis, Relapsing-Remitting type, diagnosed in 2018. Presenting symptoms included optic neuritis and numbness in the left arm. Significant clinical events include an exacerbation in March 2023 with increased weakness and gait instability, requiring a short hospitalisation. Diagnostic testing included MRI of brain and spine confirming demyelinating lesions. Diagnosis confirmed by "Dr. Thomas Kelly" at the local neurology clinic. **Relapse and Progression:** Patient reported new onset of left leg weakness and increased ataxia starting approximately 3 weeks prior to this visit. Symptoms described as moderate in severity, significantly impacting mobility and requiring increased reliance on a walking stick indoors. Patient reported these symptoms to their GP, "Dr. Sarah Chen", who advised monitoring and contacted the MS clinic. Current status involves ongoing weakness, particularly with knee flexion and ankle dorsiflexion, and persistent balance issues. Treatment used included a 3-day course of IV methylprednisolone, completed 2 weeks ago, which provided some improvement in sensory symptoms but minimal impact on motor weakness. Other influencing factors include increased stress due to family bereavement. Progression symptoms worsened since last review, particularly gait instability and lower limb weakness, starting approximately 3 weeks ago. Impact is significant, affecting independence with activities of daily living. Patient seen by GP and MS clinic about these symptoms. **Disease Modifying Therapy:** Ocrelizumab (Ocrevus) - started 2020. No reported side effects or injection site reactions. Adherence is excellent with scheduled infusions every 6 months. No home delivery issues as medication is administered intravenously at the hospital. Last MRI imaging performed in February 2024 showed stable disease. Next MRI due February 2025. Multidisciplinary team discussion in May 2020 regarding treatment options. Ocrelizumab was chosen due to its high efficacy in reducing relapse rates and progression in Relapsing-Remitting MS, delivered via intravenous infusion. Potential side effects discussed included infusion-related reactions and increased risk of infection. Monitoring requirements include regular blood tests for immune surveillance. **Related Symptoms:** **Vision:** No new or worsening vision issues reported. Patient continues to wear prescribed corrective lenses. No interventions or referrals indicated. **Balance and Coordination:** Significant issues with balance and coordination, particularly affecting gait and standing balance. Patient frequently uses a walking stick and reports near-falls. Advised to continue physiotherapy exercises and referral to Occupational Therapy for home safety assessment initiated. **Motor - Upper Limbs:** Mild weakness noted in left hand grip, but no significant impact on daily tasks. No specific interventions or referrals required at this time. **Ambulatory - Lower Limbs and Mobility:** Marked weakness in left lower limb, specifically hip flexors and ankle dorsiflexors, leading to a foot drop. Ambulates with a walking stick but reports difficulty with stairs and uneven surfaces. Discussed potential for ankle-foot orthosis; referral to Orthotics for assessment pending. **Pain:** Chronic low back pain, rated 4/10 on average, managed with over-the-counter paracetamol. No change in pain management or new interventions required. **Sensory:** Reports intermittent numbness and tingling in both feet, described as mild. No impact on function. No interventions or referrals indicated. **Bladder:** Reports occasional urinary urgency, but no incontinence. Advised on fluid management and pelvic floor exercises. No referrals needed. **Bowels:** Reports mild constipation, managed with increased fluid intake and dietary fibre. No interventions or referrals required. **Speech and Swallow:** No issues with speech or swallowing reported. **Cognition:** Reports mild subjective cognitive slowing, particularly with word-finding, but denies significant impact on daily activities. No formal assessment or intervention required at this time. **Fatigue:** Significant fatigue reported, rated 7/10. Patient describes it as overwhelming and impacting daily activities and social engagement. Advised on energy conservation techniques and pacing activities. Referral to occupational therapy may further assist with this. **Mood and Mental Health:** Reports feeling low and frustrated with current mobility limitations due to recent exacerbation. Discussed coping strategies, including mindfulness and maintaining social connections. Patient is aware of the option for psychological support if mood worsens. No current medications for mood. No immediate referral indicated. **Family Planning:** Patient is post-menopausal; no current family planning or contraception concerns. **Brain Health, Exercise, Smoking, and Diet:** Patient takes a daily Vitamin D supplement. Attempts gentle daily exercise (short walks indoors) as tolerated. Non-smoker. Diet is generally balanced, though appetite has decreased recently due to fatigue. Encouraged continued balanced nutrition. **Social Situation:** Patient is retired and lives alone. Has a strong support network of friends and family who assist with groceries and appointments. Continues with hobbies of reading and knitting. Driving status remains active, but has reduced long-distance driving due to fatigue. Benefits are stable. Home environment needs assessment for adaptations; referral to Occupational Therapy initiated for this. No advanced directives currently in place. **Co-morbidities:** Hypertension, well-controlled with Ramipril 5mg daily. **Other:** Patient expressed gratitude for the home visit and opportunity to discuss concerns in their own environment. Date of Visit: 1 November 2024.