CASE PRESENTATION ON MULTIPLE SCLEROSIS FOR PHARMACY PRESENTATION Includes SOAP notes.

1. CASE PRESENTATION ON
MULTIPLE SCLEROSIS
AYESHA FAREED
PHARM D 5TH YR
ROLL NO: 07
SVCP
1

2. CHIEF COMPLAINT: A 36YOF c/o pain and
tingling in fingers of left hand which progressed to
arm and neck
Blurred vision- right eye since 15 days
SUBJECTIVE:
PMH: HTN
FAMILY HISTORY: Nil
SOCIAL HISTORY: Nil
ALLERGIES: NKDA
2

3. OBJECTIVE:
Physical examination:
 General appearance:
Height: 165cm Weight: 65 kg BMI: 23.8 Kg/m²
 Vital signs:
Pulse: 78 beats/min
RR: 20 breaths/min
BP: 100/70mmHg
Temp: 98.2o F
HEAD TO TOE EXAMINATION:
EXT: weakness
EYE: blurred vision (right eye)
3

4. Laboratory investigations:
4
TEST VALUE REFERENCE
Albumin 3.4* 3.5-5.5 g/dl
Urea 27 20-40 mg/dl
Sr. creatinine 0.8 0.6-1.6 mg/dl
TLC 11.7* 4-11000cells/mm
Platelets 2.6 1.5-4.5lakh/mcL
Hb 14.3 13-18 g/dl
PCV 42 40-54%
MEDICATION RECONCILIATION:
• T. ESLO (amlodipine) 5mg PO OD (HTN)
• T. PANTEL (pantoprazole) 40mg PO OD

5. Diagnostic test:
 MRI: revealed acute demyelinating optic neuritis
 CSF analysis (oligoclonal bands) done- reports
awaited
DIAGNOSIS: Rt optic neuritis- Multiple
sclerosis
5

6. 6
BRAND
NAME
GENERIC NAME DOSE ROUTE FREQ INDICATION DAY
Inj.
SOLUMEDRO
L
methylprednisolon
e
1g in
200 NS
over 2
hrs
IV OD Optic neuritis D1
T. PANTODAC pantoprazole 40 mg PO OD APD D1
T. REMYLIN-
D
α-lipoic acid,
pyridoxine,
methylcobalamine
, vitamin- D
1 tab PO OD Neuropathy D1
T. DOLO paracetamol 650 mg PO OD Headache STAT
D2
T. STAMLO amlodipine 5 mg PO OD hypertension D3
T.
OMNACORTI
L
prednisolone 40 mg PO OD MS D3
T. GABAPEN gabapentin 300 mg PO HS Neuropathy D3

7. ASESSMENT:
 A 36 YOM c/o pain and tingling in fingers of left
hand which progressed to arm and neck and
blurred vision in right eye since 15 days
 MRI was done which revealed optic neuritis
MULTIPLE SCLEROSIS:
 Inj. SOLUMEDROL (methylprednisolone) 1g in
200 ml NS over 2 hrs was given as pulse therapy
 Intravenous methylprednisolone has been shown
to shorten the duration of acute exacerbations, and
it may delay repeat attacks for up to 2 years after
optic neuritis
7

8.  T.GABAPEN (gabapentin) 300mg PO HS
 T. OMNACORTIL (prednisolone) 40 mg
PO OD
 T. REMYLIN- D 1tab PO OD
HTN:
 T.S.NUMLO (amlodipine) 5 mg PO OD
APD:
 T. PANTODAC (pantoprazole) 40 mg PO
OD
8

9. PLAN
Goals:
 To decrease mortality and long term disability
 To reduce ongoing neurologic injury
 To prevent progression of the disease
 To control relapses
 To manage the signs and symptoms
9

10. Disease monitoring parameters
Monitor Blood pressure
CBC
Thyroid profile
Lipid profile
Liver enzymes
Drug monitoring parameters
 Prednisolone: Blood pressure; blood glucose,
electrolytes, intraocular pressure
 Amlodipine: BP, HR, signs of edema
 Gabapentin: depression, behavioural changes, suicidal
thoughts
10

11. Patient counselling
 Multiple sclerosis is a disease that causes vision problems,
numbness and tingling, muscle weakness, and other
problems. It happens when the body’s infection-fighting
system attacks and damages nerve cells and their
connections in the brain and spinal cord
DIET:
 Have a diet low in saturated fats and supplemented
by Omega-3 (from fatty fishes, cod-liver oil, or flaxseed
oil) and Omega-6 (fatty acids from sunflower or safflower
seed oil and possibly evening primrose oil)
 Eliminate sugar (fructose) from your diet. Keep a daily
fructose intake of not more than 25 gms
 Eliminate pasteurized milk and dairy
 Eat plenty of raw food- fruits and vegetables
 Optimize your vitamin- D levels by getting regular sunlight
exposure
11

12. DISCHARGE MEDICATIONS:
 T. S.NUMLO (amlodipine) 5 mg 1 tab orally once
daily (HTN)
 T. PAN (pantoprazole) 40 mg 1 tab orally once daily
(APD)
 T. REMYLIN- D 1 tab orally once daily (neuropathy)
 T. GABAPEN (gabapentin) 300 mg 1 tab orally once
daily after dinner (neuropathy)
 T. OMNACORTIL ( prednisolone)
40 mg 1 tab orally once daily for 1 week then
20 mg 1 tab orally once daily for 1 week then
10 mg 1 tab orally once daily for 1 week and stop
FOLLOW UP: Review with CSF reports in neuro OPD
12

13. 13