Personal Medical Journal Overview of Clinical Comprehensive History Past MS History Present MS...

What to expect during a Multiple Sclerosis Clinic Visit

- Part 2 -

Christina A. Hughes, MDDirector, MS Regional Program

VA Puget Sound Health Care SystemSeattle, WA

Personal Medical Journal

Overview of Clinical Comprehensive History

Past MS History Present MS status Functional Status Symptom Review General Medical Conditions Social Situation

Recommendations

Review from Past lecture MS Clinic

Visit – Part 1

Recommendations Maintain a Personal Medical Journal

Bring to every clinic appointment Past MS History (Diagnosis, Medication, MRI) Past Medical History List of Current Medications

Dosing amount and schedule List of Past Medication and Reason Discontinued List of Questions or Concerns Paper and Pen to Write Information and Instructions

Visit an MS Specialist Annually Visit a Primary Care Provider Annually

Review from Past lecture MS Clinic

Visit – Part 1

Part 2 - Outline

Physical Exam Neurological Exam Musculoskeletal Exam

Routine Testing Blood Work Radiology Pulmonology Ophthalmology

Specialty Testing EMG/ NCS – Electromyography / Nerve Conduction

Studies Radiology Other

Part 2 - Outline





Physical Exam - Neurological

Speech and Cognition Enunciation and motor function Word finding and conversation skills Comprehension and problem solving

Spelling Math

Memory Current Events Recall


Cranial Nerves Testing 12 pair of nerves

originating from the base of the brain

Control Motor and Sensation for Head and neck

“Follow my finger with your eyes” – CN 4 and 6

“Say, ‘Aahhh’” – CN 10 “Shrug your shoulders” –

CN 11 “Stick out your tongue” –

CN 12http://apbrwww5.apsu.edu/thompsonj/Anatomy%20&%20Physiology/2010/2010%20Exam%20Reviews/Exam%204%20Review/CH%2013%20Peripheral%20Nerve%20Terminology.htm


Upper Motor Neuron Testing Evaluates for lesions or injury in Brain and

Spinal Cord Babinski – Tickling your toes Hoffman – Flicking your finger Spasticity - Increase in muscle “tone” or

stiffness.

http://drugster.info/medic/term/babinski-response/


Reflex Testing Rated from 0 to 4+ where 2+ is normal

Evaluates Central and Peripheral Nervous System lesions

http://www.drinstruments.com/reflex-hammer.htmlhttp://www.chinamedevice.com/ChinaSuppliers/4327/Reflex-Hammer,-Neurological-Hammer,-Medical-Hammer-(DT-515F)-441997.htmlhttp://www.quickmedical.com/riester-diagnostics/reflex-hammers.html

http://www.drinstruments.com/reflex-hammer.html

http://www.chinamedevice.com/ChinaSuppliers/4327/Reflex-Hammer,-Neurological-Hammer,-Medical-Hammer-(DT-515F)-441997.html


Sensation Testing

Evaluate Central Nervous System versus Peripheral Nervous System Etiologies

Dermatome Pattern

Light Touch

Pinprick

http://bestpractice.bmj.com/best-practice/monograph/772/diagnosis.html


Coordination

Balance

Fine Motor (fingers)

Finger-to-nose

Heel-to-shin

http://www.aan.com/go/education/curricula/family/chapter8/section1


Gait – Base of support, balance, posture, step, stride, rhythm, foot placement, ankle motion, knee motion, hip motion, trunk and pelvis motion

http://www.rightdiagnosis.com/symptoms/ataxia/book-causes-5c.htm

Part 2 - Outline





Physical Exam - Musculoskeletal

Inspection and Palpation

Muscle Strength 0 – no muscle movement 1 – muscle flicker 2 – moves muscle with gravity

eliminated 3 – moves muscle against gravity 4 – moves muscle against active

resistance 5 – full strength

Range of Motion Active and Passivehttp://www.aceproindia.com/ACE%20Sample%20Projects/ePUB/Examination%20and%20Diagnosis%20of%20Musculoskeletal%20Disorders/OEBPS/10_chapter04.html

Part 2 - Outline





Routine Testing

Blood Work Complete blood count (CBC) Chemistry panel Liver function tests Vitamins D and B12 Thyroid function cholesterol hemoglobin A1C

Part 2 - Outline





Routine Testing

Radiology MRI

Brain and Cervical Spine Number and location of lesions New lesions Enhancing Lesions “Black Holes” Atrophy Other pathology – stroke, bleeding, arthritis

Noseworthy J et al. N Engl J Med 2000;343:938-952

MRI Scans of the Brain of a 25-Year-Old Woman with Relapsing-Remitting Multiple

Sclerosis

Part 2 - Outline





Routine Testing

Pulmonology Pulmonary Function Tests

DEXA Scan

http://www.qcradiology.com/bone_dens.html

Routine Testing

Ophthalmology Optical Coherence

Tomography Non invasive (done

in the clinic) Measures the retinal

nerve thickness

Optical coherence tomography findings in acute macular neuroretinopathyD Shukla, A Arora, S Ambatkar, K Ramasamy and N Perumalsamyhttp://www.nature.com/eye/journal/v19/n1/fig_tab/6701414f1.html

Part 2 - Outline



Specialty Testing EMG/ NCS – Electromyography / Nerve

Conduction Studies Radiology Other

Specialty Testing

Electromyography (EMG) Measures electrical activity of the muscles

Nerve Conduction Studies (NCS) Measures nerve health

http://painmd.tv/electrodiagnostics/

Outline





Specialty Testing

Radiology Plain X-rays Renal Ultrasound Venous and arterial Ultrasound CT-scan MRI Thoracic Spine MRI Lumbar Spine

Outline





Specialty Testing

Swallow Evaluation Bedside Video-fluoroscopic swallow study with barium

Specialty Testing Sleep

Study Measures

how you sleep

Sleep disorders can influence medical conditions and fatigue

http://www.nhlbi.nih.gov/health/health-topics/topics/slpst/during.html

Thank You!

For more information you can visit the MS Center of Excellence Website: www.va.gov/MS

Questions?

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