What should be included in a comprehensive History of Present Illness (HPI) for a patient with multiple sclerosis?

History of Present Illness (HPI) for Multiple Sclerosis

A comprehensive HPI for MS must systematically document the clinical phenotype, temporal pattern of symptoms, functional impact, and disease activity to guide treatment decisions and prognostication.

Essential Components to Document

Disease Course Classification

• Determine the specific MS phenotype by documenting whether the patient has experienced discrete relapses with recovery (relapsing-remitting), progressive worsening after initial relapses (secondary progressive), or deterioration from onset without relapses (primary progressive) 1
• Relapsing-remitting MS presents with clearly defined attacks followed by full or partial recovery, without progression between episodes, and typically affects younger patients 1
• Secondary progressive MS shows progressive deterioration for at least 6 months following an initial relapsing-remitting course, with or without superimposed relapses 2, 1
• Primary progressive MS demonstrates deterioration from disease onset without any relapses or remissions, affecting 10-15% of MS patients 1
• Document disease duration, as early relapsing-remitting MS is defined as less than 10 years from onset 2

Symptom Characterization

• Record specific neurological symptoms including sensory disturbances (numbness, tingling), motor weakness, impaired gait, incoordination, optic neuritis, and Lhermitte sign 3
• Document visual impairment patterns, particularly episodes of vision loss suggesting optic neuritis 3, 4
• Assess bladder dysfunction including urgency, frequency, or retention 3, 4
• Evaluate cognitive and behavioral symptoms as these may present with diminished insight, requiring informant corroboration 2
• Note that patients and informants may have divergent opinions about symptom severity due to impaired awareness common in MS 2

Temporal Pattern Documentation

• Establish dissemination in time by documenting when symptoms occurred, their duration, and whether they represent distinct episodes separated by at least 3 months 4
• Characterize relapse frequency by recording the number of exacerbations in the past 3 years (or 1 per year if disease duration is less than 3 years) 5
• Document the time course of symptom onset, progression, and any periods of stability or recovery 2
• Record the date of last relapse and whether the patient is currently experiencing an acute exacerbation versus chronic symptoms 6

Functional Impact Assessment

• Document impact on activities of daily living including work, self-care, mobility, and social functioning 2
• Assess disability level using standardized scales like the Expanded Disability Status Scale (EDSS), which ranges from 0 (normal exam) to 10 (death due to MS) 5
• Record specific functional limitations such as walking distance, need for assistive devices, or inability to perform specific tasks 3
• Evaluate quality of life impacts including fatigue, depression, pain, and heat sensitivity between attacks 3, 7

Informant History

• Obtain corroborating history from family members or close friends, as they often initiate evaluation and provide crucial observations that patients may not recognize 2
• Interview patient and informant separately if there is discomfort with honest reporting or overt friction 2
• Document informant observations of cognitive changes, behavioral alterations, personality shifts, and functional decline 2
• Clarify the meaning of terms like "memory loss" or "confusion" as these may differ substantially between patient/informant and clinical definitions 2

Precipitating and Modifying Factors

• Document triggers for symptom worsening including exercise, emotional stress, infection, pregnancy, or heat exposure 3, 7
• Record any factors that improve or worsen symptoms 7
• Assess tobacco use, as smoking should be strongly discouraged in MS patients 3
• Document any recent infections or other medical conditions that may have precipitated relapses 6

Prior Diagnostic Workup

• Review previous MRI findings including number and location of lesions, presence of gadolinium enhancement, and temporal changes 5, 4
• Document whether lesions show dissemination in space (different parts of CNS) and time (new lesions on serial imaging) 4, 7
• Note that 80% of new lesions in relapsing-remitting MS show gadolinium enhancement, while only 5% enhance in primary progressive MS 2, 1
• Record results of cerebrospinal fluid analysis, evoked potentials, or other paraclinical tests if performed 7

Treatment History

• Document all prior disease-modifying therapies including specific agents, duration of use, response, and reasons for discontinuation 3, 8
• Record steroid use for acute relapses, including doses, routes, and response 3, 6
• Note any use of plasmapheresis for steroid-refractory relapses 3
• Document symptomatic treatments for spasticity, bladder dysfunction, depression, fatigue, and pain 3, 4

Differential Diagnosis Exclusion

• Document evaluation for MS mimics including vascular disease, spinal cord compression, vitamin B12 deficiency, CNS infections (Lyme disease, syphilis), and inflammatory conditions (sarcoidosis, lupus, Sjögren's syndrome) 4
• Record results of testing to exclude these alternative diagnoses 4, 7
• Note that a positive test for a putative MS mimic does not automatically exclude MS diagnosis 7

Critical Documentation Pitfalls to Avoid

• Do not rely solely on patient report without informant corroboration, as diminished insight is common 2
• Do not assume stability between relapses means no disease activity, as MRI often shows asymptomatic lesion formation 2
• Do not overlook small non-enhancing lesions on MRI, as these still represent active disease 9
• Do not delay documentation of functional impact, as this guides treatment intensity and monitoring frequency 2, 3