multiple sclerosis
Doctor Information
Claire Gerrard, age 39
PMH
nil
No regular medication or allergies
PMH
nil
No regular medication or allergies
Patient Information
Claire Gerrard age 39
Your left eye is hurting, and yesterday it went a bit blurry. Your eye has been hurting on and off for the past week if you are honest, but you have been very busy and haven't had time to book an appointment. Your optician said yesterday that you need to be seen at the GP, so here you are.
If asked only- your eye is not red or light sensitive, it is just a sharp pain that feels like it is inside your eyeball. Occasionally you have had blurred vision and once you think you had double vision as well. Right now it is just the pain. You have noticed that the pain gets worse when you move your eye around, and that colours, especially red, seem less vivid than you remember. Last month you had a weird sensation in your legs - like they went numb and weren't attached to your body. It lasted for around 16 days, you thought you must haves slept funny on them on them, and when it went away, you stopped thinking about it. Your hearing is fine, you have no facial problems and your balance has been fine. There is no family history of any health problems, and you are fit and well with no medication and no allergies.
You live with your husband Derek, and four children aged between 18 and 10. This has been a busy month for you: you have been involved in a development project for a new set of flats which is due for completion in the next few weeks. Meanwhile your oldest son is about to go to university, the youngest is autistic and needs a lot of help with schooling. You are at work then you are a full time mum the rest of the time. Derek works as an oil engineer - one month on, one month off in Mongolia so half the time he is not around to help. You have probably been quite stressed lately.
You do not smoke, and have two or three glasses of wine a week.
If asked: you have a cousin diagnosed with multiple sclerosis.
Ideas: you think your symptoms could be stress related, and you are hoping they will settle down soon so you can get back to all your usual activities
Concerns: you really hope it is nothing more serious, because you don't have time to have a health problem
Expectation: to have a blood test and your vision checked out
If the potential diagnosis of multiple sclerosis is discussed with you, you are shocked and upset. You want to know all about it - what it is, how it develops - are you going to get worse and not be able to do things in future? Do you need to make any plans now? Keep interrupting the doctor as you are very anxious now and want answers. Hopefully they will calm you down and explain things well to you - you will stop panicking and agree to do whatever is suggested - you realise that the important thing is to find out what is wrong, and deal with everything later.
Your left eye is hurting, and yesterday it went a bit blurry. Your eye has been hurting on and off for the past week if you are honest, but you have been very busy and haven't had time to book an appointment. Your optician said yesterday that you need to be seen at the GP, so here you are.
If asked only- your eye is not red or light sensitive, it is just a sharp pain that feels like it is inside your eyeball. Occasionally you have had blurred vision and once you think you had double vision as well. Right now it is just the pain. You have noticed that the pain gets worse when you move your eye around, and that colours, especially red, seem less vivid than you remember. Last month you had a weird sensation in your legs - like they went numb and weren't attached to your body. It lasted for around 16 days, you thought you must haves slept funny on them on them, and when it went away, you stopped thinking about it. Your hearing is fine, you have no facial problems and your balance has been fine. There is no family history of any health problems, and you are fit and well with no medication and no allergies.
You live with your husband Derek, and four children aged between 18 and 10. This has been a busy month for you: you have been involved in a development project for a new set of flats which is due for completion in the next few weeks. Meanwhile your oldest son is about to go to university, the youngest is autistic and needs a lot of help with schooling. You are at work then you are a full time mum the rest of the time. Derek works as an oil engineer - one month on, one month off in Mongolia so half the time he is not around to help. You have probably been quite stressed lately.
You do not smoke, and have two or three glasses of wine a week.
If asked: you have a cousin diagnosed with multiple sclerosis.
Ideas: you think your symptoms could be stress related, and you are hoping they will settle down soon so you can get back to all your usual activities
Concerns: you really hope it is nothing more serious, because you don't have time to have a health problem
Expectation: to have a blood test and your vision checked out
If the potential diagnosis of multiple sclerosis is discussed with you, you are shocked and upset. You want to know all about it - what it is, how it develops - are you going to get worse and not be able to do things in future? Do you need to make any plans now? Keep interrupting the doctor as you are very anxious now and want answers. Hopefully they will calm you down and explain things well to you - you will stop panicking and agree to do whatever is suggested - you realise that the important thing is to find out what is wrong, and deal with everything later.
Examination Findings
This station requires an examination.
Pulse 69
Blood pressure 129/76
Pupils equal and reactive
HOWEVER: if a swinging light test is performed: there is an ipsilateral relative afferent pupillary light defect. (otherwise known as a Marcus Gunn pupil)
Fundi: slightly swollen optic disc.
Normal cranial nerve examination but ongoing pain in left eye, worse on movement.
Peripheral nerve examination normal
Pulse 69
Blood pressure 129/76
Pupils equal and reactive
HOWEVER: if a swinging light test is performed: there is an ipsilateral relative afferent pupillary light defect. (otherwise known as a Marcus Gunn pupil)
Fundi: slightly swollen optic disc.
Normal cranial nerve examination but ongoing pain in left eye, worse on movement.
Peripheral nerve examination normal
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination and investigation asks about family history, social history, and previous neurological symptoms Identifies abnormal findings or results and/or recognises their implications Data gathering does appears to be guided by the probabilities of disease Undertakes physical examination competently, needs to examine, fundi, cranial nerves and peripheral nerves quickly |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them |
Clinical Management Skills
|
POSITIVE INDICATORS
Makes appropriate diagnosis Develops a management plan that is appropriate and in line with current best practice Makes plans that reflect the natural history of common problems Management approaches reflect an appropriate assessment of risk Refers appropriately & co-ordinates care with other healthcare professionals Manages risk effectively, safety netting appropriately Follow-up arrangements and safety netting are adequate |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether/what to prescribe are inappropriate or idiosyncratic. Decisions on whether & where to refer are inappropriate. Follow-up arrangements are absent or disjointed Unable to construct a problem list and prioritise |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan or clarify the roles of doctor and patient Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination Does not allow own views/values to inappropriately influence dialogue |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Fails to empower patient Inappropriately influences patient interaction through own views/values Quick to judge |
Management
Explanation: Multiple sclerosis is a condition that affects the brain and spinal cord. It can cause varying symptoms that affect different parts of the body, and can come and go. There are several types of multiple sclerosis, which dictates how often you get symptoms, and how severe they may be. Whilst there is no cure at present, there are several things that can be done to improve symptoms. To get you the help you need many other specialists will need to be involved, and to confirm the diagnosis, we will need to refer you to see someone at the hospital.
Part of the challenge with MS is actually suspecting the diagnosis. Optic neuritis is quite a common presentation - look for the classic triad of eye pain worse on movement, reduced vision and reduced colour vision. Ask about strange sensations, numbness, weakness or pain in the arms or legs, even if they happened months ago, or came and went. A full neurological exam is required.
It is quite hard to explain MS in lay terms. Some people use an analogy like describing the nerves like an electric wire, where the outer coating comes off in places, and that affects the signals that go through it. Try and find an explanation you are comfortable with, so it doesn't sound awkward or overly medical.
Your job in primary care is to provide sound information to the patient, so they have some understanding of the condition and how it can affect them. Any suspicious symptoms require a referral to a neurologist for diagnosis. Usually they will arrange a scan of the head, an EEG, and various blood tests. There are many immunologic treatments and disease modifying drugs, all initiated in secondary care. There are also many support services and groups to guide sufferers through their symptoms and difficulties.
In this case the correct course of management would be to either refer to opthalmology or to neurology, for further investigations. Given that her ongoing symptoms are more visual, an urgent appointment in the eye clinic would likely be the best place to start.
Visual prognosis is good with Optic Neuritis, with most people noticing a recovery of visual symptoms within 5-6 weeks. Rarely; some people may be left with long term visual disturbance. The risk of progression to MS from optic neuritis alone varies according to which study you read, most quote around 40-50% at around 10-15 years. Optic neuritis has a recurrence rate of around 35% over the same time period.
for further reading please read the Optic Neuritis Treatment Trial (ONTT)
Part of the challenge with MS is actually suspecting the diagnosis. Optic neuritis is quite a common presentation - look for the classic triad of eye pain worse on movement, reduced vision and reduced colour vision. Ask about strange sensations, numbness, weakness or pain in the arms or legs, even if they happened months ago, or came and went. A full neurological exam is required.
It is quite hard to explain MS in lay terms. Some people use an analogy like describing the nerves like an electric wire, where the outer coating comes off in places, and that affects the signals that go through it. Try and find an explanation you are comfortable with, so it doesn't sound awkward or overly medical.
Your job in primary care is to provide sound information to the patient, so they have some understanding of the condition and how it can affect them. Any suspicious symptoms require a referral to a neurologist for diagnosis. Usually they will arrange a scan of the head, an EEG, and various blood tests. There are many immunologic treatments and disease modifying drugs, all initiated in secondary care. There are also many support services and groups to guide sufferers through their symptoms and difficulties.
In this case the correct course of management would be to either refer to opthalmology or to neurology, for further investigations. Given that her ongoing symptoms are more visual, an urgent appointment in the eye clinic would likely be the best place to start.
Visual prognosis is good with Optic Neuritis, with most people noticing a recovery of visual symptoms within 5-6 weeks. Rarely; some people may be left with long term visual disturbance. The risk of progression to MS from optic neuritis alone varies according to which study you read, most quote around 40-50% at around 10-15 years. Optic neuritis has a recurrence rate of around 35% over the same time period.
for further reading please read the Optic Neuritis Treatment Trial (ONTT)