LOVETT · Multiple Sclerosis

Patient Details

Name: Georgie Lovett
Age: 42 years
Opening statement: “I have been having some pins and needles in my foot”

Clinical Details (First Consultation)

For one week: pins and needles in the left foot and leg, accompanied by weakness of the same leg. The symptoms are constant; nothing makes it better or worse. Over the past two days you have become unsteady when walking, with a tendency to go to the left. Your whole leg is feeling “weak”.

Response Guidance

Open questions

If asked to say more about the problem, describe the symptoms as above.

Closed questions only

This is your fifth such attack in the past six months (previous episodes eased after a few hours).
First episode six months ago whilst abroad: hot weather, long walk; left leg became weak and you had to be helped back to the hotel. Symptoms improved over two hours. Did not seek medical review.
You think the problem is probably caused by a trapped nerve and have no other underlying concern. Expecting the doctor to confirm your self-diagnosis.
Off work for the last two days because of feeling unsteady.
No trauma/injury/head injury. No headaches, visual changes, colour vision changes, slurred speech, facial droop, word-finding difficulties, or upper limb issues.
No bladder or bowel trouble. No respiratory, cardiac, weight loss, fever, night sweats or skin changes.

Patient’s Perspective (ICE & Feelings)

Ideas: You think this is probably caused by a trapped nerve.
Concerns: No underlying concern.
Expectations: You are expecting the doctor to confirm your self-diagnosis.

Past Medical History

No significant past medical history

Drugs & Allergies

Nil regular medication
No known allergies

Family History

Father: hypertension (well controlled)
Mother: breast cancer, in remission (developed age 70)

Social History

Police officer
Married, no children (although thinking about starting a family)
Non-smoker
Alcohol: 2–4 glasses of wine over the weekend

Important Social, Cultural or Behavioural Characteristics

You are a confident, well-organised person with a straightforward attitude to health, illness and life. You see problems and challenges to be overcome and have an expectation that solutions can always be found. You have never faced any major adversity in life up to this point.

Simulated Patient Non-Verbal Behaviour / Demeanour

Smartly dressed. No non-verbal cues to suggest anxiety or depression. Present your story in a straightforward manner.

(Optional: subtle drag of left foot when walking from waiting room — only just obvious there is a problem; not excessive.)

Information for the Student (before first consultation)

Name: G Lovett · Age: 42
PMH: No significant past problems reported
Last consultations: 1 year ago – 40+ check (BP 136/78, lipids normal); 2 years ago – flu-like illness
Current medication: Nil

Physical Examination Findings

Drags the left leg with a tendency to walk to the left
Left leg: tone increased but power decreased; knee and ankle reflexes brisk; extensor plantar response; sensation decreased in all modalities up to the knee
Right leg: Normal

Facilitator Notes – Diagnosis & Management (First Consultation)

Most likely: Multiple sclerosis (remitting/relapsing nature; sensory and motor modalities; central nervous system pathology). If correctly elicited there are no other plausible provisional diagnoses.

Less likely: Spinal lesions causing nerve root entrapment; syringomyelia (very unlikely).

Management: Explain that the problem lies with the nervous system (degree of sharing is a key teaching point). Advise rest with social support; do not drive. Urgent referral to neurology outpatient clinic. Urgent GP review if significant worsening.

Second Consultation – Actor Script

You attend three weeks after referral. Seen in outpatients the following week and admitted two days later for investigations. Advised to see GP one week after discharge. Hospital follow-up arranged in four weeks. No treatment given.

Things have almost totally resolved (only mild weakness of left leg). You are happy and optimistic that all is well. Hospital gave no alternative opinion or potential diagnosis prior to discharge, reinforcing your view that all is well.

Opening statements

“You will be pleased to see I am now almost completely better, all of those tests weren’t necessary after all.”
“The hospital said they would write to you, have you received the letter?”

Any statement that an abnormality was detected is greeted with disbelief or perceived as minor. You are inquisitive and will press for more explanation.
Possible responses: “Surely you have got the wrong patient”; “The laboratory must have made a mistake”; “But I’m so well, it can’t be anything serious”; “It must be a virus I picked up from abroad, it’s getting better now.”
If multiple sclerosis is mentioned abruptly → denial, shock and aggression: “No that can’t be right”; “Are you sure you know what you are talking about? I want to see the consultant.”
If the doctor is evasive or dishonest → anger to the point of confrontation.
If the doctor shows empathy and honesty → you accept the diagnosis but need a lot of help to take a positive approach. To you MS implies a wheelchair existence and the end of life as you know it. You are too well informed to accept bland, over-optimistic reassurance.
Once accepted, enquire about treatment possibilities, your job, and plans to start a family. “Research is being done all the time, they must have found something that works by now…”

Further Information for Student (before second consultation)

Discharge letter from Consultant Neurologist (Dr B Rain):

Georgie was admitted from clinic for investigation of recurrent episodes of paraesthesia and weakness of the left leg. On admission: increased tone and reduced power in left leg with hyperreflexia; bilateral extensor plantars; sensory deficit in left leg and right foot; evidence of cerebellar dysfunction.

Brain scan showed multiple focal areas of demyelination. Findings and lumbar puncture results fully consistent with a diagnosis of multiple sclerosis.

Outpatient appointment arranged in 4 weeks to discuss significance. May be suitable candidate for monoclonal antibody therapy; funding application to be discussed then.

Primary Care Block · University of Buckingham