Multiple Sclerosis Intake CL

IDENTIFICATION:
The patient was seen at the Neurology Clinic at Regional Headache and Neurology Specialists on November 13, 2025.

REASON FOR FOLLOW-UP:
Assessment of chronic neurological symptoms including headaches, muscle fasciculations, lower back pain, urinary incontinence, weight loss, and sleep disturbances.

HISTORY OF PRESENTING ILLNESS:
The patient reports chronic headaches persisting since at least May of this year, lasting three to seven days, characterized by sensations of pressure and occasional stabbing or burning pain. Over-the-counter analgesics such as acetaminophen provide partial relief, but symptoms recur. Rizatriptan was trialed last year with only temporary benefit. Over the past year, the headaches have become more frequent and intense, with burning sensations described as a liquid-like feeling accompanying the pain. The patient denies visual aura or other classic migraine features.

Muscle fasciculations have been present for approximately three years, initially localized but now involving larger muscle groups, including the face, thigh, and biceps. The fasciculations are more pronounced during periods of rest or sleep. There has been no improvement with pregabalin, which was titrated up to 225 mg daily before discontinuation. Fasciculations are described as sporadic, with variable intensity over time.

The patient experiences chronic lower back pain exacerbated by prolonged sitting, such as during school attendance and commuting. Significant fatigue and numbness in the back are reported upon returning home. Previous magnetic resonance imaging of the thoracic and cervical spine in June 2024 and August 2025 revealed a minor disc herniation in the lumbar region contacting the thecal sac but not impinging on neural elements. No surgical intervention has been recommended. The patient avoids pain medications due to gastrointestinal concerns and has not received sacroiliac joint injections, although these were discussed with a pain specialist in May and July of the previous year.

The patient reports nocturnal enuresis occurring variably, with two episodes in the past week and sometimes absent for several weeks. The patient is undergoing pelvic floor physiotherapy, and further evaluation is ongoing to determine the etiology.

There has been unintentional weight loss of approximately thirty pounds over the past two years, with ten to twelve pounds lost in the last eight weeks. The patient is under the care of a gastroenterologist for ongoing evaluation of possible malabsorption, with additional gastrointestinal symptoms including pain and diarrhea following fatty food intake. Blood work to date has been unremarkable.

The patient reports disrupted sleep with frequent nocturnal awakenings, typically two to three times per night, not attributable to urinary symptoms or external factors. Despite sleeping nine to ten hours, the patient does not feel excessively fatigued in the morning but finds the sleep pattern abnormal. The patient does not consume caffeine and reports no clear precipitating factors.

The patient describes a persistent sense of dysregulation and difficulty concentrating, which has progressively worsened over the past three years. Counseling was previously attempted but provided limited benefit due to ongoing physical symptoms. There is no reported history of seizures, visual disturbances, or other high-risk symptoms affecting driving safety.

EXAMINATION:
No physical examination findings were documented at this visit.

CRANIAL NERVE EXAMINATION:
Not documented.

MOTOR EXAMINATION:
Not documented.

SENSORY EXAMINATION:
Not documented.

ASSESSMENT AND PLAN:
The patient presents with chronic neurological symptoms, including persistent headaches, muscle fasciculations, lower back pain, urinary incontinence, weight loss, and sleep disturbances. There is no evidence of motor neuron disease or structural abnormalities on imaging studies. Functional neurological disorder and benign fasciculations are likely contributing to the symptoms.

RECOMMENDATIONS:
Repeat MRI of the brain to investigate the etiology of the headaches.
No further diagnostic testing planned for muscle fasciculations; discussed the benign nature of fasciculations and the potential diagnosis of functional neurological disorder.
Referral to a pain specialist for further evaluation and management of lower back pain, including consideration of sacroiliac joint injections. Recommended continuation of physiotherapy and ergonomic adjustments.
Continue pelvic floor physiotherapy for urinary incontinence; further evaluation ongoing.
Continue follow-up with the gastroenterologist for ongoing evaluation and management of weight loss and gastrointestinal symptoms.
No specific interventions discussed for sleep disturbances at this time.
Provided information about in-house counseling services and offered a referral for psychological support.
Reinforced the benign nature of findings and discussed the importance of acceptance and functional management strategies.

It was a pleasure seeing the patient. I recommend ongoing multidisciplinary management and will arrange for the repeat MRI of the brain and referral to pain specialists as discussed. Please do not hesitate to contact me if there are further questions or concerns.

Dr. Jamie Carter, Neurology
Regional Headache and Neurology Specialists