Clinic note template for a patient with multiple sclerosis
Explanation: (for the pre-written note, look for the example note below)
- History of MS when it started - work up- previous relapses - DMTs tried in the past.
In patients with multiple sclerosis, we need to screen for:
A- Any relapse since last clinic visit.
B- Compliance/Side effects from disease modifying therapy
C- Complications of MS:
System wise mnemonic:
- Motor: Weakness - Spasticity & Stiffness - Gait problems
- Sensory: Neuropathic pain - Uhthoff phenomenon
- Autonomic dysfunction : Constipation, urine incontinence, sexual dysfunctions
- Higher cortical: Cognitive decline / Memory problems - Mood disorder "depression" - Fatigue
Another way to remember is "A-J" mnemonic:
A (anxiety) - B (Bowel - bladder - sexual) - C (Cognitive) - E (Exercise - employment) - F (Fatigue) - G (Gait, weakness, spasticity) - H (Heat, Uhthoff's) - I (Insomnia) - J (Jolts: spasms/neuropathic pain)
D- Last work up:
Routine workup for DMT
-Gilenya (Fingolimod): Pre-screen: CBC, EKG, VZV IgG, macular edema screen Follow up: CBC & LFT every 6 months
-Aubagio (Teriflunamide): Pre-screen: LFT - Pregnancy test Follow up: LFT q1month - BP for HTN every visit.
-Tcfidera (Dimethyl fumarate): Pre-screen: CBC (lymphocytic count should be > 1000) - JC virus titer - Follow up: CBC every 6 months
-Tysabri (Natalizumab): Pre-screen: Serum JC virus Ab with index Follow up: Sr JCV Ab q6 months - Screen for PML.
-Lemtrada (Alemtuzumab): Pre-screen: CBC, CK, TSH, skin exam, make sure patient is immune against Varicella (either vaccination or prior infection, if negative then get VZV Ab and vaccinate if not immune) Follow up: CBC, CK, urinalysis with cell count every month - TSH every 3 months
Work up for MS
-Last MRI brain:
-Last MRI spine:
Example for clinic note
Mr GH is a 35-year-old patient with past medical history of multiple sclerosis who presented to the clinic today for follow up.
Patient was diagnosed with RRMS at age of 31 years (2013) after an episode of Lt optic neuritis. At that time patient was treated with pulse steroids with complete resolution of symptoms. Work up at that point showed contrast enhancement of Lt optic nerve, another enhancing lesion in Rt corona radiate and multiple non-enhancing white matter lesions consistent with MS. MRI spine was non-remarkable. CSF showed positive OCB with elevated IgG index.
Patient was started on fingolimod in 12/2013 with no relapses.
- No symptoms suggestive of relapse since last clinic visit.
- Patient is compliant with Gilenya with no side effects.
- Screening for MS complications:
- No Weakness, spasticity, stiffness or gait problems
- No neuropathic pain, reports blurring of vision in hot weather and after hot bath.
- No constipation, urine incontinence or sexual dysfunctions
- No reported memory problems, denies depression or fatigue
Last work up:
Pre-screen labs 2012: Normal CBC (lymphocytic count 1000), EKG, VZV IgG negative, passed macular edema screen
Last CBC/LFT (12/2016) was normal (lymphocetic count 700)
Work up for MS
-Last MRI brain (12/2016):
-Last MRI spine (12/2016):