Multiple Sclerosis Follow Up Clinic

**Relapse/Progression:** Relapse: Patient reports a relapse of symptoms starting approximately 2 weeks ago, on 18th October 2024. Initial symptoms included increased fatigue and tingling in the left leg. Symptoms have gradually worsened, with the patient now experiencing significant weakness in the left leg, making walking difficult. The patient reported these symptoms to their GP. The patient was prescribed a course of oral steroids, which provided some relief initially, but the symptoms have since returned. The patient denies any recent infections or significant stress. Symptoms are now: increased fatigue, tingling in the left leg, and significant weakness in the left leg. Progression: Patient reports worsening of mobility since last review. They report increased difficulty walking and are now using a walking stick. They have seen a physiotherapist about the symptoms. **Disease Modifying Therapy:** Current DMT: Ocrevus, started in 2022. No current side effects reported. Last MRI was performed in June 2024, next MRI due in December 2024. **MS Related Symptoms:** **Mood:** Patient reports low mood, which is impacting their ability to engage in hobbies. They are currently seeing a therapist and taking Sertraline 50mg daily. **Memory/Cognition:** Patient reports some memory difficulties, particularly with short-term memory. They are using a memory aid app on their phone. **Lower Limbs/Mobility:** Patient reports increased difficulty walking and are now using a walking stick. They have seen a physiotherapist about the symptoms. **Bladder:** Patient reports increased frequency of urination, especially at night. They are managing this with fluid restriction in the evening. **Fatigue:** Patient reports significant fatigue, which is impacting their daily activities. They are using pacing strategies and taking regular breaks. **Pain/Sensory:** Patient reports some neuropathic pain in their feet, which is worse at night. They are taking Gabapentin 100mg at night. **Brain Health/Exercise/Smoking/Diet:** Patient is encouraged to continue with regular exercise and maintain a healthy diet. Advised to stop smoking. **Social Situation:** Patient reports they are unable to work due to their symptoms. They are receiving disability benefits and have a strong support network. **Co-morbidities:** Patient has a history of hypertension, well controlled with medication. **Management Plan:** * Review medication for mood. * Referral to Occupational Therapy for home assessment. * Continue with physiotherapy. * Patient to continue with current management strategies. These notes were generated by Heidi AI with the consent of the patient.