MS Annual Review Document

Specialised Nurse **Management Plan:** 1. Continuation of Ocrelizumab 300mg IV infusion every six months. The next infusion is scheduled for May 2025. 2. Start Gabapentin 300mg twice daily for neuropathic pain. Titrate as needed. 3. Referral to Neuro-Physiotherapy for gait training and balance exercises. 4. Annual MRI brain and cervical spine in October 2025. 5. Follow-up appointment with MS Specialist Nurse in six months, May 2025. **Overview of Current Status:** Diagnosis: Relapsing-Remitting Multiple Sclerosis (RRMS). Currently stable with no new disease activity. Previous Disease-Modifying Therapies: Interferon Beta-1a (discontinued due to tolerability issues), Fingolimod (discontinued due to breakthrough disease activity). Patient reports a gradual increase in fatigue over the past three months, impacting her ability to perform daily tasks. She also describes new intermittent burning sensation in her left foot, occurring daily. No acute relapses or significant worsening of pre-existing neurological symptoms since the last review. Denies any new vision changes, severe weakness, or bladder dysfunction. **Review of Systems:** * **Vision:** No new visual disturbances reported. Occasional blurry vision when fatigued. * **Balance and Coordination:** Occasional unsteadiness, particularly on uneven surfaces. Reports no falls. * **Motor Function in Upper Limbs:** Mild weakness noted in left hand grip, otherwise unremarkable. * **Mobility and Lower Limbs:** Reports increased stiffness in lower limbs, requiring a walking stick for longer distances. New neuropathic pain in left foot. * **Pain:** New burning sensation in left foot (neuropathic). Chronic low back pain, managed with paracetamol. * **Sensory Symptoms:** Numbness in right hand, stable. New burning sensation in left foot. * **Bladder and Bowel Function:** Occasional urinary urgency, managed with fluid restriction. Bowel function normal. * **Speech and Swallowing:** No dysarthria or dysphagia. * **Cognitive Changes:** Reports mild memory lapses, particularly with word recall, stable. * **Fatigue:** Significant, chronic fatigue, worsening over past 3 months. * **Mood or Mental Health:** Reports feeling low at times due to fatigue and chronic pain, denies significant depressive symptoms. No anxiety. **Current Medications:** * Ocrelizumab 300mg IV infusion every 6 months * Baclofen 10mg twice daily (for spasticity) * Paracetamol 1g three times daily (as needed for pain) * Vitamin D 1000 IU daily **Medication Adherence and Tolerability:** Patient reports excellent adherence to Ocrelizumab infusions. Notes mild post-infusion fatigue for 24-48 hours. Baclofen is tolerated well with no significant side effects. Expresses willingness to start Gabapentin for new neuropathic pain. **Social Situation:** Employed part-time as an administrative assistant. Drives short distances. Strong support network from husband and two adult children. Enjoys gardening and reading but reduced engagement due to fatigue. Denies alcohol or recreational drug use. Receives Personal Independence Payment (PIP). **Activities of Daily Living:** Patient uses a walking stick for outdoor mobility. Symptoms, particularly fatigue and lower limb stiffness, significantly impact participation in social activities and ability to sustain gardening for extended periods. Requires assistance with heavy household chores. **Physical Examination:** * **Mental Status:** Alert and oriented to person, place, and time. Speech clear. Affect congruent. * **Cranial Nerves:** Pupils equal, round, and reactive to light. Extraocular movements intact. Visual fields full to confrontation. Facial sensation symmetrical. Facial movements symmetrical. Gag reflex present. Tongue protrudes in midline. Hearing grossly intact. * **Motor Strength:** 5/5 in bilateral upper extremities except 4/5 in left hand grip. 4/5 in bilateral lower extremities, more pronounced on the left. * **Reflexes:** 2+ and symmetrical in biceps, triceps, brachioradialis. 3+ and symmetrical in patellar and Achilles, with bilateral ankle clonus (2-3 beats). * **Coordination:** Dysmetria noted on left finger-to-nose. Mild intention tremor bilaterally. Heel-to-shin test dysmetric on the left. * **Gait:** Spastic-ataxic gait, requiring a walking stick for stability. Romberg's test positive with eyes closed. * **Sensory Testing:** Decreased pinprick and light touch sensation in right upper extremity (glove distribution). Decreased vibration sense in both lower extremities up to the knees. New allodynia to light touch on left foot. **Co-Morbidity Optimisation:** Patient has essential hypertension, well-controlled with Ramipril 5mg daily. No other significant co-morbidities impacting MS management. **Functional Assessment Score:** Expanded Disability Status Scale (EDSS) score: 5.0 (estimated). **Recent Imaging:** MRI brain and cervical spine performed on 1 November 2023: Stable, no new T2 lesions or gadolinium-enhancing lesions compared to prior study (October 2022). Next MRI due October 2025. **Laboratory Results:** Full blood count, liver function tests, renal function tests, and Vitamin D levels from 1 November 2024 were all within normal limits. Next routine bloods due May 2025. **Assessment:** Patient with Relapsing-Remitting MS, currently stable on Ocrelizumab with no evidence of new inflammatory activity. New neuropathic pain and worsening fatigue are impacting functional status and quality of life. Overall, disease appears stable, but symptomatic management needs optimisation. **Patient Education:** Discussed rationale for starting Gabapentin for neuropathic pain, potential side effects, and titration schedule. Provided information on fatigue management strategies and referred to MS Society resources. Emphasised importance of regular physiotherapy and adherence to DMT. Discussed upcoming MRI and follow-up plan.