Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
New or follow-up for multiple sclerosis (MS)
(Specify) Symptoms vary depending on the affected area(s) of the central nervous system (CNS). In early stages, symptoms may be absent. Common complaints include:
Relapses: Episodes of worsening neurological function (weakness, numbness, vision problems, balance difficulties) that develop over days or weeks and then improve partially or completely over weeks or months.
Fatigue: A common and often debilitating symptom.
Spasticity: Muscle stiffness and tightness.
Cognitive impairment: Problems with memory, concentration, or thinking.
Pain: Can include various types of pain like neuropathic pain, headaches, or muscle pain.
Bladder or bowel problems: Urgency, frequency, or incontinence.
Depression or emotional changes: Common due to the chronic nature of the disease.
History of Present Illness:
Onset, duration, and severity of current symptoms (if applicable).
For established MS:
Date of diagnosis and disease course (relapsing-remitting, primary progressive, etc.).
Frequency and severity of past relapses.
Response to previous treatments (improvement or progression of symptoms).
Any new or worsening symptoms.
Past Medical History:
Comorbid medical conditions (e.g., depression, urinary tract infections).
History of vaccinations (vaccination is generally safe in MS).
Family History:
Family history of MS (increases risk but is uncommon).
Medications:
List all current medications, including disease-modifying therapies (DMTs), medications for symptom management (e.g., pain, spasticity, fatigue), and any other relevant medications.
Social History:
Assess impact of MS on daily life, work, and social activities.
Physical Exam:
Neurological examination: Evaluate for:
Muscle weakness or numbness
Coordination problems
Abnormal reflexes
Visual disturbances
Speech or language difficulties
Cognitive function (brief bedside assessment)
Assessment:
Multiple sclerosis: Based on clinical presentation (characteristic symptoms, relapses), supportive neurological examination findings, and in some cases, positive MRI findings.
Disease course: Classified based on the pattern of disease progression:
Relapsing-remitting MS (RRMS): Most common type, characterized by relapses followed by periods of remission.
Secondary progressive MS (SPMS): Develops in some RRMS patients, characterized by steady progression of disability.
Primary progressive MS (PPMS): Steady worsening of symptoms from onset, with no distinct relapses.
Differential Diagnoses:
Consider other conditions that can mimic MS symptoms:
Neuromyelitis optica (NMO)
Spinal cord disorders
Stroke
Brain tumors
Vitamin B12 deficiency
Imaging Studies:
Magnetic resonance imaging (MRI) of the brain and spinal cord: Essential for diagnosis and monitoring disease activity. May show characteristic lesions in the white matter.
Laboratory Tests:
No specific diagnostic blood test for MS.
Some tests may be done to rule out other conditions or assess for potential comorbidities (e.g., complete blood count (CBC), electrolytes, vitamin B12 level).
Plan:
Treatment:
Disease-modifying therapies (DMTs): Medications that can slow disease progression and reduce relapse frequency. The choice of DMT depends on various factors like disease course, patient characteristics, and tolerability.
Symptom management: Medications and therapies to address specific symptoms like spasticity, pain, fatigue, and bladder/bowel dysfunction.
Rehabilitation: Physical therapy, occupational therapy, and speech therapy can help maintain function and independence.
Follow-up: Regular follow-up visits with clinical evaluation and potentially MRI scans to monitor disease activity and treatment response.
Education:
Educate the patient about MS, the different types, and the course of the disease.
Discuss treatment options and potential benefits and side effects.
Provide information about managing symptoms and maintaining a healthy lifestyle.
Offer resources and support