A 36-year-old female with a medical history of Multiple Sclerosis (MS) complains of constantly feeling tired even after a period of rest or sleep. She was diagnosed with MS 3 years ago and has been on Interferon. As a wife and mother of 2 with a full-time job, she states that by the end of the day, she has no energy whatsoever. The patient explains that she began noticing her lack of energy and tiredness a few months back, but it has gotten progressively worse. She also mentions that she has missed several days at work over the last 4 weeks because after getting showered and dressed, she had no energy left to go to work. Reports occasional glass of wine on the weekends, denies tobacco or illicit drug use. She has tried some CBD oil to help with energy without relief. Reports sleeping more than eight hours a night while needing several naps throughout the day. She reports an uncomfortable buzzing sensation traveling from the neck to the spine with what sounds like a Lhermitte’s sign. She denies loss of bowel or bladder. She denies fever, chills, weight loss, or weight gain. She reports some nasal congestion but contributes to allergies which she takes cetirizine 10 mg PO daily. Reports she is up to date on her pap smear. She does a monthly self-breast exam, which she denies concerns about. She saw her dentist and eye doctor within the last year and has no issues or concerns. Reports her mother, who is alive, has diabetes and hypertension. Her father and siblings are also alive without any health issues. She has an aunt on her mother’s side who also had MS and currently uses a wheelchair. She is alert and oriented to person, place, time, and situation. Does not appear in acute distress, is well-developed, and is slightly obese in the abdominal section. Skin is dry, warm, and intact. Normocephalic, neck supple, no thyromegaly. PERRLA is about 4mm pupil size. Conjunctivae rim pale. Optic fundi examined revealed a uniform red to pink color; the disk is pale pink, vessels emanate from the optic cup, and the fovea was slightly darker. Retinal vessels are free from hemorrhages or exudates. Face symmetrical. No lymphadenopathy. The oral mucosa is pink and moist. Heart rate bradycardic at 56 beats per minute but regular without pauses or extra beats. Lungs diminished bilaterally but otherwise clear. Abdomen soft, non-distended, bowel sounds normoactive in all four quadrants. No suprapubic or CVA tenderness. Able to differentiate between light and deep tough, no dysmetria or ataxia, normal alternating hand movements, gait steady. Muscle tone inspected and palpated, free from fasciculation, tenderness, or atrophy. Strength 5/5 in all extremities.
Example/ guide with required subtopics.
S (Subjective):
Chief complaint: Complains of constantly feeling tired even after a period of rest or sleep.
HPI: A 36-year-old female with a medical history of Multiple Sclerosis (MS) comes to the office
with complains of constantly feeling tired even after a period of rest or sleep. She was diagnosed
with MS 3 years ago and has been on Interferon since then. She explains that she began noticing
her lack of energy and tiredness a few months back, but it has gotten progressively worse. She
also mentions that she has missed several days at work over the last 4 weeks because after
getting showered and dressed, she had no energy left to go to work. She has tried some CBD oil
to help with energy without relief. Additionally, she reports sleeping more than eight hours a
night while needing several naps throughout the day. She also reports an uncomfortable buzzing
sensation traveling from neck down to spine with what sounds to be a Lhermitte’s sign. No
further complaints currently.
PMH: Multiple Sclerosis (MS) and seasonal allergies
Allergies: No medication or food allergies, does seem to have seasonal allergies that she is
currently taking medication for.
Current Mediation: Cetirizine 10 mg PO daily and Interferon with unknow dose.
Social History: She is a wife and mother of 2 with a full-time job, reports an occasional glass of
wine on the weekends, denies tobacco use or illicit drug use.
Family History: Her mother who is alive has diabetes and hypertension. Her father and
siblings are also alive without any health issues. She does have an aunt on her mother’s side who
had MS as well who is currently wheelchair bound
Health Maintenance/Promotion: She is up to date on her pap smear, does monthly self-breast
exam, denies concerns on exam. Saw her dentist and eye doctor within the last year and no
issues or concerns there.
ROS:
General: She denies fever, chills, weight loss or weight gain. She reports some nasal congestion
but contributes that to allergies which she takes cetirizine 10 mg PO daily for.
Skin: No complaints
HEENT: She denies any denies hearing changes, headaches, or dizziness. She does appear
slightly obese in the abdominal section.
Neck: She reports uncomfortable buzzing sensation traveling from neck down to spine with what
sounds to be a Lhermitte’s sign.
CV: No complaints
Pulmonary: No complaints
GI: No complaints.
GU: She denies loss of bowel or bladder.
PV: Denies any swealing or discomfort of extremities
MSK: No complaint of weakness. She does report some uncomfortable buzzing sensation
traveling from neck down to spine with what sounds to be a Lhermitte’s sign.
Neuro: No complaints
Endo: She is alert, oriented to person, place, time and situation. Does not appear in acute
distress. No complaints.
Psych: No complaints.
O (Objective)/Physical Exam
VS: Heart rate 56 beats per minute
Skin: Skin is dry, warm, and intact.
HEENT: Normocephalic, neck supple, no thyromegaly. PERRLA about 4mm pupil
size. Conjunctivae rim pale. Oral mucosa pink and moist. Optic fundi examined revealed
uniform red to pink color, disk is pale pink, vessels emanate from optic cup, fovea was slightly
darker. Retinal vessels are free from hemorrhages or exudates. Face is symmetrical.
Neck: No lymphadenopathy.
CV: Bradycardic but regular without pauses or extra beats
Pulmonary: Lungs diminished bilaterally but otherwise clear
GI: Abdomen soft, non-distended, bowel sounds normoactive in all four quadrants.
GU: No suprapubic or CVA tenderness.
PV: No swelling noted.
MSK: Muscle tone inspected and palpated, free from
fasciculation, tenderness or atrophy. Strength 5/5 in all extremities.
Neuro: She is alert, oriented to person, place, time and situation. Does not appear in acute
distress. Able to differentiate between light and deep tough, no dysmetria or ataxia, normal
alternating hand movements, gait steady.
Psych: She is alert, oriented to person, place, time and situation.
Diagnostics Test: N/A
A (Assessment)
Problem #1
Constantly feeling tired even after a period of rest or sleep.
Most Likely Diagnosis #1 – Lassitude fatigue or Nerve fiber fatigue due to multiple sclerosis
(MS)
Plan (P):
Diagnostics: The patient already has a diagnosis of MS, and fatigue is a common side effect
from this condition. We can differentiate between the two common forms of fatigue
by obtaining a more detailed history. For example, lassitude fatigues the onset can be random
and have no caused vs. Nerve fiber fatigue is caused by exertion or heat exposure.
As fatigue could be caused by other conditions, blood work up should be completed to rule out
other possibilities. Such as a CBC to rule out infection or Vit D level check as that can cause
fatigue as well.
Therapy/Treatment: Depending on what is causing MS fatigue, then providers will place a
treatment plan. Once other possibilities for fatigue have been ruled out, than provider may
provide anti-inflammatory pain medication, such as aspirin BID have been shown to reduce MS
fatigue. Amantadine, an antiviral medication, has also been shown to help MS fatigue, but the
mechanism for treating fatigue is unknown. Another medication option will also be armodafinil
or modafinil which are medication used in the treatment of narcolepsy. Which have shown to
promote wakefulness in people with MS fatigue.
Education: the patient needs to be educated that people with MS fatigue need to take frequent
breaks and recharge their batteries. The patient needs to learn to divide large projects into smaller
ones. Plan her days ahead and factor in naps and breaks. Keeping the house cool may
help improve her fatigue and to avoid warm or hot environments. Using a dehumidifier may help
cool the house in humid weather is present. Having physical or occupational therapy may also
help by teaching the patient about simplifying tasks at work and home and establishing an
exercise routine.
Consultation/Collaboration: Neurologist and therapist
