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Multiple Sclerosis Collection of Case Studies. Case Study 1.
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Case Study 1 • A male patient aged 44 years first experienced an episode of acute vision loss at age 22. This episode resolved without treatment over a two week period. Then, at age 29, the patient experienced an episode of transverse myelitis at spinal level T4. The patient was hospitalized and underwent a CT scan, myelogram, and cerebrospinal fluid (CSF) analysis, all with normal findings. The patient was therefore diagnosed with likely MS, which was not treated. This episode resolved with minimal residual leg numbness. At age 44, after working for years as a security guard, he was laid off due to an oversight on the job. When he was unable to gain alternative employment, DVR referred him to a neurologist for a re-evaluation of his history of possible MS.
Continuation… • The patient had no additional attacks since age 29 and his examination shows no physical disability. However MRI scans showed multiple hyperintense lesions in the periventricular white matter with moderate atrophy. Continued work with DVR has established that the patient has low employment potential due to cognitive impairment; neuropsychological testing has been ordered but the results are still pending. When shown his MRI scan, the patient expressed a strong desire to begin MS treatment. His health insurance is due to expire in two months.
Discussion Points • What should be done to help this patient? • Is he a candidate for DMTs? • What programs or services are available to him? • What is your long term plan?
Case Study 2 • An otherwise healthy 29 year old woman with a history of migraines visited the Emergency Department with a severe headache. He also had a history of intermittent paresthesias of the face, hands, and feet which she thought might have been brought on by stress. The patient reports the occurrence of MS in her maternal aunt. Her general physical and complete neurologic examination were normal. Her brain MRI showed fairly extensive nonspecific T2 abnormalities throughout the deep subcortical white matter without rounded or ovoid configuration. The corpus callosum and posterior fossa were normal. None of the lesions were juxtacortical or justaventricular. T1 scans showed no hypointensities or enhancement with GD after a five minute delay.
Discussion Points • Is this MS? • What do you think is the problem? • What additional assessments should you do as a nurse?
Case Study 3 • A male patient age 35 is an executive who works 50-60 hours per week. He travels frequently. He was diagnosed with MS 7 years ago and initially he had infrequent exacerbations. He was treated with both oral and IV steroids. Two years ago he developed bilateral lower extremity weakness, a T10 sensory level, and forgetfulness. Treatment with glatiramer acetate was initiated at that time. Currently, the patient does not feel he is getting better; therefore he administers GA intermittently. Although he has difficulty with self-injection, he will not ask his family for assistance. Over time he has become increasingly anxious and isolated and his social and work relationships have suffered.
Discussion Points • What is your assessment of this patient? • How can we help? • What would be your initial recommendation? • Follow-up?
Case Study 4 • Susan is a 24 year old woman with MS diagnosed three years ago. She has been taking DMT for two years with an inconsistent routine of injections and minimal healthcare follow up. She lives with her boyfriend and they have a very active lifestyle. She works full time and has a busy social life getting 3-4 hours of sleep each night and eating irregularly. Medications consist of DMT, OTC headache medications, oral contraceptive, and Provigil 200 mg. bid. She presents at your office complaining of nausea, vomiting, dizziness, and severe fatigue. Neurologic examination is negative except for a positive Romberg test. U/A via dipstick is positive for leukocyte esterase. Vital signs BP 120/80; HR 100, lungs clear. Patient is afebrile. LMP six weeks ago.
Discussion Points • Is this a relapse? Pseudo relapse? • UTI? What is the differential? • What tests are indicated?
Case Study 5 • Charles is a 31 year old male who has been Copaxone treatment for 3 years. He previously experienced 1-2 relapses annually; this has been reduced to less than 1 per year. He lives alone and has intermittent assistance from a community program. He complains of short term memory problems and difficulty with ADL’s. The patient calls early one Friday morning requesting a referral to a dentist. He states that he has had facial pain for about one week and needs to see a dentist. When questioned by the nurse, it was determined that the pain emanates from his ear to his chin and is worse at night.
Discussion Points • What is your assessment? • What treatment should be initiated? • Does the patient need a dentist? • MRI?
Case Study 6 • Patty is 32 years old. She works full time as a nurse. She is married with one child. She has had MS for 10 years and is on an injectable therapy. Her MRI is positive for 9 hyperintense lesions, 2 enhancing lesions, and one infratentorial lesion. She has been feeling more fatigue lately and her legs are very stiff. She does not take any medications for her fatigue or stiffness. She presents at your clinic asking about the risks if she stops her therapy and becomes pregnant.
T2 Weighted Images Conventional T2 FLAIR Fluid Attenuated Inversion Recovery
Discussion Points • What is your assessment? • What are her primary needs at this time?
Case Study 7 • A 34 year old woman was diagnosed in 1992 and presents for further help in your office. Initially she experienced a relapsing-remitting course with mild and infrequent exacerbations. However, several years later she had a severe attacks that left her with paralysis of both legs and bladder retention. After discharge from a rehabilitation facility, she required a walker and motorized tricart for mobility. Her current symptom management includes amantidine for fatigue, oxybutynin chloride for bladder urgency and frequency, and methanamine hippurate to improve urine acidity. The takes gabapentin for pain and has counseling, rehabilitation, and support group services to help her cope with her ongoing disability. She presents at your practice requesting treatment with disease modifying therapy since her support group has urged her to consider this; they stated that “it is not too late for you.”
Discussion Points • What would you recommend at this time? • How can you help this patient realistically?
Case Study 8 • Cindy is a 34 year old woman who was diagnosed with MS two years ago. She is on an injectable medication and is very adherent to the protocol. She feels fine in the morning but in the afternoon her walking worsens and she is subject to fatigue. She heard that dalfampridine is now available and she has decided to stop her injections and ask for a prescription for this oral therapy. Her reason is that her insurance has an annual limit and she prefers to spend her insurance dollars to help her to walk better. • You are a nurse practitioner/PA in her MS Center. The neurologist has refused to give her a prescription for dalfampridine and now Cindy is requesting her records so she can go elsewhere for her care.
Discussion Points • What would your first step be? • How do you help this patient set priorities? • How can you help her to make realistic decisions? • How can you advocate on her behalf?
Case Study 9 • Stan is a 22 year old man who just graduated from college. Upon returning from a trip to Europe to celebrate his graduation, he experienced dizziness and blurring of vision in his right eye. He thought he was just fatigued so he rested before he started looking for a job. His symptoms worsened and he began having balance problems. He saw his primary care physician who referred him to a neurologist. Following a full examination, MRI, and lumbar puncture, he was given the diagnosis of MS. The neurologist suggested that he begin an injectable therapy immediately to reduce the risk of worsening disease and subsequent relapses. Stan started searching the Internet and reviewed all the current research in MS. He found there were several studies using oral medications. He also reviewed the efficacy data on currently approved injectables. He then visited the neurologist and stated that he decided to wait for the oral medications to reach the market. He was very reluctant to inject even once a week and would prefer to take a pill to control his disease.
What are the major challenges with this patient? • What is your assessment of this situation? • What are your first actions? Discussion Points
Case Study 10 • Judy is a 36 year old married woman with two children. She recently had her second child, a healthy baby girl. She is currently breast feeding and does not want to stop until the baby is six months old. She is experiencing blurring of vision in her right eye but does not want steroid treatment because it would mean that she would have to stop breast feeding. She was on a injectable medication prior to becoming pregnant but she is even reluctant to restart since she states that injecting “tied her down.” She prefers to wait for the pill. This woman is at high risk post partum for an MS relapse.
What are your concerns in this situation? • What can you do to help her? • What other help can you enlist? • What plans are realistic in light of the problems this patient is facing? Discussion Points
Case Study 11 • John is an African American man with a 10 year history of MS. He has never had a relapse but has experienced slow progression since his diagnosis. He is self-injecting daily but feels he is getting worse despite this therapy. He walks with bilateral supports; he no longer works; he is extremely depressed; and his wife recently divorced him. He wishes to stop therapy, start dalfampridine, and be placed on the list for an oral disease modifying therapy.
Discussion Points • Should we support his decision to stop his injectable therapy? • Would an oral disease modifying therapy be appropriate for him? • Would dalfapridine help his symptoms • What other interventions might help him?
