MS clinic

Neurologist 01/11/2024 Sarah Jane Smith NHS-1234567890 20/05/1985 (39 years old) CRN-987654321 Reason for Attendance: Follow-up appointment for established Multiple Sclerosis. Diagnosis: Relapsing-Remitting Multiple Sclerosis (RRMS). Symptom Onset: April 2018 Date of Diagnosis: 15/09/2019 Current DMT: Ocrelizumab 600mg IV infusion every 6 months, last infusion 01/08/2024. Previous DMT(s): Dimethyl Fumarate 240mg BID (stopped due to persistent GI side effects in 2021). Other Diagnoses: Hypertension Migraine with aura Other Medications: Amlodipine 5mg OD Sumatriptan 50mg PRN Actions for GP and Recommendations: Please monitor blood pressure regularly. Please ensure patient has access to migraine management resources. Assessment: I was pleased to meet Sarah today. She attended the appointment accompanied by her husband, Mr. John Smith. Sarah reports a stable period since her last review, with no new relapses or significant worsening of existing symptoms. She continues to experience occasional mild fatigue, particularly in the late afternoon, which she manages with regular rest breaks. She also notes some intermittent tingling in her left hand, which has been present for several months but is not progressive and does not impact her fine motor skills. She describes her walking as generally good, though she feels less steady on uneven surfaces. Her balance can occasionally be affected, but she denies any falls. Overall, she feels her current treatment is effective in controlling her MS. Maximum walking distance before the patient needs to stop: Approximately 500 meters due to fatigue. Spasticity: lower limbs - mild - no functional impact. Past medical history: Childhood asthma, appendicectomy (2000). Smoking status: Non-smoker. Alcohol intake: 5 units per week. History of vaccinations: Up-to-date with routine vaccinations, including annual flu jab and COVID-19 vaccinations. Family planning status, contraceptive methods used, and parity: Patient is P2G2, using oral contraceptive pills (combined pill). Known medication allergies: Penicillin (rash). MS-Related Symptoms: Fatigue: Managed with regular rest periods and pacing activities. Paresthesia (left hand): Monitored, currently no specific management beyond observation as symptoms are mild and non-progressive. On Neurological Examination: Mental: Awake, fully orientated, normal speech and language, able to provide detailed account of symptoms. Cranial nerves: I: not tested. II: normal ophthalmoscopy, present venous pulsations, no visual field defects, normal visual acuity. III-IV-VI: PERLA 3 mms, normal ocular movements. Central primary gaze. No primary- or gaze-evoked nystagmus. V: normal facial sensation. Corneal reflexes present bilaterally. VII: symmetric facies. Normal bilateral eyelid closure, symmetric nasolabial folds. VIII: normal gross auditory function. IX-X: symmetrical soft palate in primary position and retraction. Central uvula. XII: central tongue, normal trophism, normal movements, no fasciculations. Motor: power 5/5 in 4 limbs both proximally and distally. Normal neck flexion and extension. Reflexes ++/++++ symmetrical in 4 limbs. Bilateral plantar flexor response. Sensory: normal light touch and pallesthesia. Mild reduction in vibration sense in bilateral lower extremities. Coordination: no dysmetria or dysdiadochokinesis in finger-to-nose and heel-to-shin testing bilaterally. Normal tone and trophism. Gait: Mild unsteadiness on tandem gait. No meningeal irritation signs. No abnormal movements. Current EDSS: 3.0 Last Images: Brain MRI: 01/05/2024 - Stable appearance, no new T2 lesions or gadolinium-enhancing lesions compared to previous scan. Spinal MRI: 01/05/2024 - No new lesions, stable appearance of existing C-spine lesions. Labs: FBC: 28/10/2024 - WNL. LFTs: 28/10/2024 - WNL. U&Es: 28/10/2024 - WNL. Vitamin D: 28/10/2024 - 75 nmol/L (normal). Analysis: Sarah has Relapsing-Remitting MS and is currently stable on Ocrelizumab. Her neurological examination shows mild, non-progressive deficits consistent with her established diagnosis and EDSS score. MRI findings are stable, indicating no new disease activity. Her current symptoms of mild fatigue and intermittent paresthesia are well-managed and do not significantly impact her daily life. The discussion focused on maintaining her current treatment regimen given its effectiveness and her good tolerability. Treatment options were reviewed, reaffirming that Ocrelizumab remains the most appropriate choice given her stable disease course. Sarah expressed satisfaction with her current treatment and its tolerability. We also discussed the importance of continuing a healthy lifestyle to support overall well-being. Recommendations for managing fatigue were reiterated, including the importance of regular exercise, adequate sleep, and energy conservation techniques. We briefly discussed mood, noting that Sarah reports generally good mood but is aware of support services if needed. Plan: * Continue Ocrelizumab 600mg IV infusion every 6 months. * Continue routine blood monitoring (FBC, LFTs, U&Es) prior to each infusion. * Multidisciplinary team involvement: Continue regular reviews with MS specialist nurse for ongoing support and symptom management advice. * Follow-up imaging plan: MRI monitoring will continue at one-year intervals, with the next scan due in May 2025. * Recommendations for the GP: Please continue to manage hypertension and migraines as per current guidelines. No immediate changes to current medication are required. Continue to monitor for any new or worsening symptoms. * Patient education and resources provided or recommended: Re-provided MS Society leaflet on fatigue management. Discussed online resources for MS patients. * Follow-up plan: Next neurology clinic review in 6 months, around May 2025. * Lifestyle recommendations discussed: Emphasised importance of a balanced diet, regular moderate exercise, and stress reduction techniques. Yours sincerely, Dr. Eleanor Vance, FRCP Consultant Neurologist Neurology Department Royal Infirmary of Edinburgh