Relapsing-Remitting Multiple Sclerosis - problem list?

I am a first year Physiotherapy student here in the UK and I have some practice case studies to look at and practice with before a practical examination in September. The exam briefly consists of identifying the patient problems, explaining different intervention options and then performing examples of the chosen interventions. One of the practice materials is a 29 year old female with recently diagnosed relapsing-remitting MS and I am having trouble formulating a patient problem list. In the exam they only want a maximum of 3 problems as the exam is timed. Here is the case study below:

PC	Referred to your outpatient clinic by neurologist to treat current S&S and discuss long-term management. Patient presenting with a recent history of trips but has not fallen. Hyperreflexia especially in the L lower limb. She has widespread muscle weakness, which is affecting her confidence in the kitchen and taking care of her children.
HPC	5/12 ago noticed difficulty with routine tasks e.g. getting up from the floor when playing with the children. Needed to steady herself feeling unbalanced as though her R knee would give way. However, this settled and improved so did not bother the GP. 2/12 later she dropped a cup and felt clumsy her arm and hand would shake when she was carrying out an activity (ATAXIA). Again, the S&S went away quite quickly. A month ago, she had an episode of blurred vision and unable to see colour, so she went to see the GP who referred her to a neurologist. After multiple investigations, she has a diagnosis of relapsing remitting MS 1/52 ago.
PMH	Nil of note
SH	She lives with her partner and 3 young children. She is a current smoker of 10/day. She is a full-time nurse working in cardiac care and she works her shifts around her family. She commutes by car to work and lives in a terraced house with 3 bedrooms and a toilet upstairs.
S	She is complaining of fatigue and that she has to keep resting during the day. She is feeling overwhelmed by her diagnosis and how this going to impact her life and her family going forward. She tells you about her recent trips and the problems she is having taking care of her children. Patient states she has reduced confidence 6/10
O	Patient walks in with wide BOS and is having problems clearing the floor with her left foot. On examination, she has widespread muscle weakness of 4/5 (oxford scale) and increased resistance to PROM especially in the Left LL. Romberg’s test 40 seconds.

Some of the patient problems I have come up with is widespread muscle weakness and problems with gait. I also highlighted recent history of trips, however I am unsure. I also need to explain what parts of the subjective history indicate that this is a problem. Do you guys think I am on the right lines with my patient problem list? What would you suggest from the case study? This is one of the few practice case studies I have looked at so I want to feel confident before my exam in September and when I go onto placement in November.

Hi,
thanks for sharing this. What a lovely case study.
It would be fabulous if other students could join in and collaborate on the task.

A slight difficulty is that your are still in 1st year and we simply have no idea what you have been taught so far and in which depth the answers need to be.
E.g. have you learned about the International Classification of Functioning, Disability and Health (ICF) framework yet?
Also, if your exam is in September, does this mean that you will have more lectures for this topic?
Have you discussed a sample case study in class? Would you be able to give us this study and the problem/ intervention list that that the lecturer supported/ discussed?

You are off to a very good start.
I recommend for you to go (and other students in this Forum as well) through the text again and every time you think "this is not normal", underline the words.
This might give you a few more pointers. :)
You could copy and paste the text as a reply.

Looking forward to hearing from you again,
cheers,
Fyzzio

Hi Fyzzio,

Thank you for your reply! There are no more lectures on this topic since my exam is postponed until September due to Covid-19. We have discussed a sample case study in class where my lecturer wrote an essay-style response for us to look at, which I can attach if appropriate.

Since your post I have looked a little more into the case study and started my next level of analysis. I also agree with Fyzzio and it would be great to have some discussion with other Physio students! This is what I have come up so far:

Patient Problem	Subjective history that indicates this is a problem
1. Widespread muscle weakness	- 4/5 oxford scale - Increased resistance to PROM left LL – high muscle tone? - Recent history of trips could be due to muscle weakness as well as balance and coordination? - Reduced confidence 6/10 – especially caring for her children and performing ADL’s in the kitchen - Difficulty getting up off the floor - Ataxia
2. Problems with balance/decreased balance and coordination	- Romberg test 40 seconds - Feeling unbalanced like her right knee would give way after getting up from the floor - Previous signs of ataxia, clumsy and shaking arm - Recent history of trips - Reduced confidence 6/10 - Wide BOS and problems clearing floor with left leg - Hyperreflexia in L lower limb

I feel like this is a good start at formulating my thoughts and underlining problems in the case study. I would love to have everyone's opinion on my notes so far, and whether anyone else could see any other problems for the list? I am still thinking about problems with her gait as a potential problem, however I am unsure if this fits in with balance or co-ordination or whether it would be it's own separate problem?

Many thanks.