Multiple Sclerosis Letter

**Clinic:** Follow Up **Clinic Tests:** * 25ft Timed walk: 6.2 seconds * Weight: 15 stones * Blood Pressure: 130/80 * EDSS: 4.5 * Neuro Exam: Verbal prompt - Patient able to follow instructions and answer questions appropriately. Outcomes - Normal reflexes, no sensory deficits. **Diagnosis:** Diagnosed with Relapsing Remitting MS in 2018. Presenting symptoms included fatigue and visual disturbances. Initial diagnosis confirmed by MRI and VEPs. Patient has experienced several relapses since diagnosis. **Relapse/progression:** Patient reports a relapse of fatigue and increased weakness in the left leg, starting approximately 2 weeks ago. Symptoms are moderately severe, impacting mobility and daily activities. Patient reported symptoms to their GP. Patient was prescribed a course of steroids, which provided some relief. No other factors have influenced the relapse. **DMT:** * Currently on Ocrevus, started in 2020. No significant side effects reported. Last MRI performed in June 2024, next due in December 2024. Patient is seen by Dr. Smith. **MS Related Symptoms:** * *Fatigue*: Started in 2018, impacting daily activities and work. Patient is concerned about the impact on their ability to work. Patient takes Amantadine for fatigue. Referral to Occupational Therapy for fatigue management. * *Lower limb/walking*: Increased weakness in the left leg, started 2 weeks ago, impacting mobility. Patient is concerned about falls. Referral to Physiotherapy for gait assessment and mobility aids. **Social/Brain Health:** Patient is currently working full-time. Home life is stable. Patient is taking Vitamin D supplements. Patient is currently exercising 3 times a week. No weight issues. Patient is driving. Patient is in receipt of PIP. **Mutually agreed action plan:** * Continue with Ocrevus treatment. * Referral to Occupational Therapy for fatigue management. * Referral to Physiotherapy for gait assessment and mobility aids. * Next follow-up appointment scheduled for 1st November 2024. **This letter was generated by Heidi AI with the consent of the patient.** **NOTE TO ADMIN:** Add referrals and copy to patients/GP/Consultant, delete this section once added.