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MS

AA

Abdul Rahman Alothman

Transcript

MULTIPLE SCLEROSIS

Group C

09/12/2019

College of Pharmacy

Subjective:

Chief Complaint:

“My legs are numb and weak, and I’m having trouble walking and urinating.”

HPI:

Loretta Mansfield is a 26-year-old woman who was in excellent health until 4 days ago, when she developed numbness and tingling in her left foot. Over the course of the next 4 days, the numbness extended higher up her leg to her lower abdomen, stopping at the umbilicus, and then going down the right leg. She also developed weakness in both of her legs, is having trouble walking, and is bothered by urinary urgency.

SOAP

PMH:

  • Frequent migraine headaches since adolescence, that have been difficult to control despite therapy with acetaminophen, aspirin, and caffeine (Excedrin) and oral sumatriptan.
  • Mild recurrent bouts of depression that have not been treated pharmacologically.
  • Obesity most of her life.

Subjective:

FH:

  • There is no family history of neurologic disease.

SH:

Subjective

  • Smoked one pack per day for 8 years; use of alcohol is limited to an occasional glass of wine or beer on weekends.

Meds:

  • Acetaminophen, aspirin, and caffeine (Excedrin) two tablets PO PRN headache
  • Sumatriptan 50 mg PO PRN migraine, at the onset of pain

Allergies:

  • NKDA

Objective:

VS:

Gen:

The patient is a Caucasian woman who appears to be slightly anxious but is otherwise in NAD

Physical Examination:

Objective

  • CNs II–XII are intact with the exception of abnormal saccadic movements on horizontal gaze; no signs of optic neuropathy.
  • Motor: Tone, bulk, and strength are 5/5 in both arms, with good fine motor movements. In the legs, she has 4/5 strength in an upper motor neuron pattern, with normal tone and bulk.
  • Sensory: Moderately diminished light touch, pain, and temperature in both legs with a cord level at the umbilicus and decreased vibratory sensation in both great toes. (+) Romberg sign.
  • Gait: Mildly unsteady on tandem walking. Timed 25-foot walk was 5.2 seconds.
  • Reflexes: 2/2 in UE, 3/3 in LE; (+) Babinski bilaterally.
  • The patient is alert, oriented, and cooperative. No Lhermitte’s sign is noted.

Objective:

Labs:

Lumbar Puncture:

CSF analysis shows opening pressure 140 mm H2O, 10 WBC/μL, 97% lymphocytes; protein 30 mg/dL, glucose 65 mg/dL; IgG index 1.7; 12 oligoclonal bands unique to CSF

MRI Scan:

  • Thoracic spine MRI with and without injection of contrast material reveals a one segment long enhancing lesion in the posterior thoracic spine at level T10.

  • Brain MRI shows multiple areas of T2 and FLAIR hyperintense lesions; four were periventricular,

  • one was in the left cerebellum, two were juxtacortical; none of the areas enhance after injection of contrast material.

  • A total of 12 T2 and FLAIR lesions were seen in the brain.
  • Arrows highlight typical periventricular white matter lesions seen in multiple sclerosis.

Assessment:

  • Clinical isolated syndrome
  • Untreated indication
  • Migraine headache

Assessment

  • Ineffective medication
  • Mild recurrent attacks of depression
  • Untreated indication
  • Obesity (BMI: 34.7)
  • Tobacco smoking

Plan:

Pharmacological management:

  • Initiate Prednisolone Acetate 200 mg/day PO for 1 week, then 80 mg/day PO to be tapered over 2-3 weeks.

CIS

  • Initiate Interferon B-1a (Avonex) 30 mcg/0.5 ml IM once weekly.
  • to decrease flu-like symptoms, may initiate once-weekly dosing with 7.5 mcg (week 1) then increase dose of 7.5 mcg once weekly (weeks 2 to 4) up to recommended dose of 30 mcg once weekly.

Non-pharmacological management:

  • Initiate Multidisciplinary rehabilitation:

Cognitive, behavioral therapy

Physical, occupational therapy

Symptomatic treatment:

Bladder Dysfunction:

  • Initiate oxybutynin (Ditropan XL) 10 mg orally once/day

Symptomatic treatment

Vitamin D deficiency:

  • Initiate Ergocalciferol 50,000 UI orally once weekly for 4 weeks, then follow with maintenance dose of 1500 UI daily

Vaccination:

cont..

  • Annual Influenza vaccine

Goal of therapy:

  • Resolve the symptoms
  • Prevent further attacks

Goal of therapy

  • Prevent progression
  • Improve QOL

Monitoring parameters:

  • Thyroid function tests
  • CBC with differential

Monitoring

  • LFTs
  • Sings/symptoms of psychiatric disorders
  • MRI every 6 months

Counseling

Educate the patient about the proper way of administering IM injection:

  • Rotate injection site
  • Do not inject into area where skin is irritated
  • 2hr after injection, examine the site for redness, tenderness.

Counseling

  • Advise the patient to increase Dietary Vitamin D intake
  • Educate the patient about the signs and symptoms
  • Educate the patient about the important of medication adherence
  • Encourage the patient to attend the rehabilitation sessions and her appointments.

Plan:

Pharmacological management:

  • Switch sumatriptan to zolmitriptan 2.5 mg may repeat after 2 hours
  • Continue acetaminophen, aspirin, and caffeine (Excedrin)

Migraine Headache

non-pharmacological management:

  • Avoid triggers
  • Regular sleep cycle
  • Relaxation therapy

Cont..

Goal of therapy:

  • Relieve migraine attack
  • Prevent recurrence

Plan:

  • Pharmacological management:

  • Initiate Venlafaxine 75mg orally once daily. may increase dosage by 75mg\day every 4 days. maximum 225mg\day.

Depression

Non-pharmacological management:

Cognitive behavioral therapy (CBT)

Cont..

Monitoring parameters:

1 - serum sodium level

2 - signs\symptoms of serotonin syndrome

3 - Evaluate the response after 4 to 6 weeks

Plan:

Educate the patient about the important of smoking cessation,

if the patient is willing to quit, then:

Smoking

Start nicotine replacement therapy

  • Nicotine patch
  • 21 mg/24 hours for 4 weeks
  • 14 mg/24 hours for 2 weeks
  • 7 mg/24 hours for 2 weeks

Patient Counseling:

Patient counseling

  • Apply patch on a relatively hairless location typically between the neck and waist
  • Rotate the site
  • Apply as soon as you wake

Plan:

1- Initiate Lifestyle modification:

  • Reduce calorie intake
  • Physical activity at least 30 min everyday
  • Educate the patient about the importance of adherence
  • Inform the patient about the complication of being obese and how outcomes may improve the quality of life when losing weight

Obesity

2-Refer the patient to a dietitian specialist

Goal of Therapy

  • Prevent obesity complication
  • Improve quality of life
  • Long-term changes of eating behavior by monitoring food intake

Goal of therapy

References

  • Marcus, J. F., & Waubant, E. L. (2013, April). Updates on clinically isolated syndrome and diagnostic criteria for multiple sclerosis. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726117/.

References

  • Efendi, H. (2015, December). Clinically Isolated Syndromes: Clinical Characteristics, Differential Diagnosis, and Management. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5353226/.
  • Treatments of CIS. (n.d.). Retrieved from https://www.nationalmssociety.org/What-is-MS/Types-of-MS/Clinically-Isolated-Syndrome-(CIS)/Treatments.

Any Questions?

"The art and science of asking questions is the source of all Knowledge".

-Thomas Berger

Thank you for listening.