CASE STUDIES

1. CASE STUDIES

2. Case Study #1 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.

3. Questions: Case Study #1…continuation What is your assessment? What treatment should be initiated? Does the patient need a dentist? MRI?

4. Case Study #2 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 methanaminehippurate 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.”

5. Case Study #2…continuation Questions: • What would you recommend at this time? • How can you help this patient realistically?

6. Case Study #3 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.

7. Questions: Case Study #3…continuation • What is your assessment of this patient? • What are her primary needs at this time?

8. Case Study #4 Charles is a 59 year old male who has been treated with a disease modifying therapy for 7 years. He previously experienced 1-2 relapses annually; this has been reduced to less than 1 per year. He stopped working 5 years ago. He lives alone and no longer drives. He complains of short term memory problems and difficulty with ADL’s. The patient calls the MS clinic 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.

9. Case Study #4…continuation Questions: 1. What is your plan of care? • Refer the patient to a local dentist • Prescribe an NSAID prn and advise the patient to rest • Schedule an immediate follow-up visit for a neurologic examination • Schedule a cranial MRI

10. Case Study #4…continuation Questions: 2. Three months later, the patient is seen in your office very unkempt and anxious. He has stopped his medication because he no longer can afford it. He has bruises on his knees although he denies falling. He holds onto to chairs or furniture for ambulation. What is your plan of care? • Arrange for transportation to the local Emergency Room • Refer the patient to a local community agency for a social service and rehabilitation evaluation • Schedule a visit with a neuropsychologist • Restart disease modifying therapy

11. Case Study #4…continuation Questions: 3. Cognitive impairment in multiple sclerosis can result in: • Deficits in long-term memory • Alteration in executive function • Worsens with aging • Improvement with stimulation and rehabilitation