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What to expect during a Multiple Sclerosis Clinic Visit - Part 1 -

What to expect during a Multiple Sclerosis Clinic Visit - Part 1 -. Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound Health Care System Seattle, WA. Outline. Personal Medical Journal Overview of Clinical Comprehensive History Past MS History Present MS status

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What to expect during a Multiple Sclerosis Clinic Visit - Part 1 -

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  1. What to expect during a Multiple Sclerosis Clinic Visit- Part 1 - Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound Health Care System Seattle, WA

  2. Outline • Personal Medical Journal • Overview of Clinical Comprehensive History • Past MS History • Present MS status • Functional Status • Symptom Review • General Medical Conditions • Social Situation • Recommendations

  3. Outline • Personal Medical Journal • Overview of Clinical Comprehensive History • Past MS History • Present MS status • Functional Status • Symptom Review • General Medical Conditions • Social Situation • Recommendations

  4. Personal Medical Journal • Physician Names and contact information • Section for Multiple Sclerosis (MS) diagnosis information • Section for current MS status • Section for documentation of Each MS Symptom • Page for characteristics, tests done, equipment used • Page for equipment used and treatments • Page for current medication and tried/failed medication • Section for General Medical Conditions

  5. Personal Medical Journal Example - Symptom: Fatigue • Characteristics: • All day, interferes with activities • Relieving Factors: • Naps, CPAP machine, Medication, Cooling Vest • Worsening Factors: • Stress, Heat • Tests: • Sleep Study: Positive for Obstructive Sleep Apnea • Medical workup: Positive for low thyroid • Medical workup: Negative for Depression, Anemia, Vitamin Deficiencies

  6. Personal Medical Journal Example - Symptom: Fatigue • Equipment: • CPAP machine • Cooling Vest • Home AC Unit • Treatments • Medication for fatigue • Medication for low thyroid • Scheduled Rests • Energy Saving Techniques

  7. Personal Medical Journal Example - Symptom: Fatigue Current Medication • Amantidine 100 mg twice a day • No Side Effects Trialed Medicine • Methylphenidate 5 mg in the morning and 5 mg at noon. • Stopped after 2 weeks due to increased anxiety

  8. Outline • Personal Medical Journal • Overview of Clinical Comprehensive History • Past MS History • Present MS status • Functional Status • Symptom Review • General Medical Conditions • Social Situation • Recommendations

  9. Comprehensive History • Past MS History • Present MS Status • Functional Status • Symptom Review • General Medical Conditions • Social Situation

  10. Past MS History • Diagnosis • When diagnosed • Who (neurologist, PCP, etc.) • How (MRI, Lumbar puncture, symptoms, etc.) • What category (Relapsing Remitting, Primary Progressive, etc) • Symptoms • When started • What was presentation

  11. Past MS History • Disease Modifying Treatment (DMT) • What medication • When started/stopped • How many doses • Why discontinued • Interferon Beta 1a Avonex, Rebif • Interferon Beta 1b Betaseron, Extavia • Glatiramer Acetate Copaxone • Fingolimod Gilenya • Natalizumab Tysabri • Mitoxantrone Novantrone • Methotrexate

  12. Past MS History • Relapse History • How often • Clinical presentation • Treatment • MRI • When taken • What part of body (Brain, spine) • Where are lesions located • How many lesions • What other results noted

  13. Comprehensive History • Past Multiple Sclerosis (MS) History • Present MS Status • Functional Status • Symptom Review • General Medical Conditions • Social Situation

  14. Present MS Status • Relapses • How often • Symptoms • Treatment • Date of last relapse • Progressive Neurologic changes • Motor or sensation changes • DMT • Adherence • Side Effects

  15. Comprehensive History • Past Multiple Sclerosis (MS) History • Present MS Status • Functional Status • Symptom Review • General Medical Conditions • Social Situation

  16. Functional Status • Independent • Modified Independent • Supervision/Set up • Contact Guard Assist • Minimal Assist (requires < 25 % help) • Moderate Assist (requires 25-49 % help) • Maximum Assist (requires 50-74 % help) • Dependent (requires >75 % help)

  17. Functional Status • Mobility • Assistive Devices • Cane / crutches • Walker / Rollator • Manual or Power Wheelchair / Scooter • Distance • Equipment • Braces, Functional Electrical Stimulator • Transfers • Falls (tripping, balance, attention) • Home Exercise Program • Medication • Ampyra

  18. Functional Status • Activities of Daily Living (ADLs) • Basic • grooming, toileting, bathing, dressing, eating • Instrumental • finances, shopping, meal prep • Home Modifications • Ramp, grab bars, roll-in shower • Equipment • Reacher, shower chair, raised toilet seat, Hoyer lift • Driving/transportation • Adaptive equipment • Accidents or near accidents • Aide and attendant care

  19. Comprehensive History • Past Multiple Sclerosis (MS) History • Present MS Status • Functional Status • Symptom Review • General Medical Conditions • Social Situation

  20. Symptom Review: Skin • Characteristics: • Tears, abrasions, pressure ulcer • Location • Pressure Ulcers • Treatments: • Ointments • Dressings • Debridement • Wound Vacuum • Surgical Intervention – Skin or Muscle Flaps

  21. Symptom Review: Cognition-Speech • Characteristics: • Memory • Thought Processing • Concentration • Speaking difficulties: Word finding, soft voice • Testing: • Neuropsychological Tests • Treatments: • Adaptive Techniques • Speech Language Pathology Therapy • Medication: • Memantine, Donepezil, stimulants

  22. Symptom Review: Swallowing • Characteristics: • Coughing after liquid or solid intake • Gagging or Choking • Testing: • Clinic Swallow Evaluation • Radiological Swallow Evaluation • Treatments: • Modified Diet • Adaptive Techniques • Tube Feeding: PEG or PEJ

  23. Symptom Review: Fatigue • Characteristics: • Morning, afternoon, evening • Relieving and worsening factors • Tests: • Evaluate current medication • Evaluate Sleep • Evaluate for Depression • Evaluate for low thyroid, anemia, vitamin deficiency • Treatment: • Naps • Scheduled Rest Periods • Energy Saving Techniques • Heat Sensitivity: Cooling Vest, Home, Car Air Conditioning • Medication: • Amantadine, Stimulants, Modafinil

  24. Symptom Review: Sleep • Characteristics • Falling Asleep • Staying Asleep • Nocturia, Pain, Spasticity, Noise • Awakening Refreshed • Snoring • Tests: • Sleep Studies • Treatment: • Adaptive Devices • CPAP, mouth guards, custom bracing/support • Medication: • Trazodone, Zolpidem, Benzodiazepines

  25. Symptom Review: Spasticity • Characteristics: • Arms or legs • Tightness or jerking motions • Worsening and Relieving Factors • Interferes with… or Helps with… • Treatment: • Stretching Regimen • Bracing • Medication: • Baclofen – Oral or Intrathecal Pump • Tizanidine, Dantrolene, Gabapentin • Botox Injections

  26. Symptom Review: Bladder • Characteristics: • Hesitancy, Urgency, Frequency, Incontinence, Pain • Tests: • Evaluate for Urinary Tract Infections • Evaluate for Retention – Post Void Residuals • Evaluate for Kidney or Bladder Stones • Radiological testing • Treatment: • Timed Voids, Double Voids, Crede Maneuver • Catheters • Medication: • Oxybutynin, Tolterodine, Tamsulosin

  27. Symptom Review: Sexual Concerns • Characteristics: • Erectile Dysfunction, Low Libido, Pain • Testing: • Evaluate hormone levels • Evaluate for Depression • Treatment: • Optimizing medical conditions • Optimizing functional limitations • Adaptive equipment • Counseling • Medication: • Tadalafil, Sildenafil

  28. Symptom Review: Bowel • Characteristics: • Constipation • Diarrhea • Incontinence • Tests: • Evaluate Dietary Intake: Fluid, Fiber • Radiological Testing • Treatment: • Consistent Daily Bowel Regimen • Improve Diet and Exercise • Medication: • Stool Softener, Bulk Forming Agent • Motility Agent, Enema

  29. Symptom Review: Mood • Characteristics: • Depression, PTSD • Irritability, Anger • Anxiety • Suicidal thoughts • Treatment: • Counseling • Optimize Exercise and Social Interaction • Medication: • SSRI, SSNRI, Tricyclic Antidepressants, Stimulants

  30. Symptom Review: Pulmonary • Characteristics: • Shortness of Breath • Coughing • Pneumonia • Medical Conditions: COPD, Asthma • Testing: • Pulmonary Function Tests • Radiological Studies • Treatment: • Optimize medical conditions • Pulmonary Rehabilitation • Assistive Devices • Medication: • Inhaled and oral

  31. Symptom Review: Vision • Characteristics: • Blurry vision, Double Vision, Loss of Vision • Pain • Difficulty with tasks (reading, driving, watching TV) • Tests: • Neuro Ophthalmology evaluation yearly • Radiological Studies • Treatment: • Prescription lenses • Adaptive Equipment • Visual Rehabilitation

  32. Symptom Review: Pain • Characteristics: • Where – stationary or radiating • Aching, burning, stabbing, tingling • Relieving and Worsening Factors • Testing: • Radiological Studies • Electromyography and Nerve Conduction Testing • Treatment: • Physical Therapy • Modalities: Massage, TENS unit, Ultrasound • Medication: • Pain Contract • Tylenol, NSAIDs, Narcotics, Topical • Injections • Pain Pumps

  33. Symptom Review: Sensation • Characteristics: • Numbness, Tingling, Highly sensitive to touch • Clumsiness • Lhermittes Sign • Tests: • Evaluate for medical conditions like Diabetes • Nerve Conduction Tests • Treatment: • Desensitization Therapies • Medication: • Anti-epileptics – Gabapentin, Pregabalin • Tricyclic Antidepressants – Nortriptyline, Amitriptyline • SSNRIs – Venlafaxine, Duloxetine

  34. Comprehensive History • Past Multiple Sclerosis (MS) History • Present MS Status • Functional Status • Symptom Review • General Medical Conditions • Social Situation

  35. General Medical Conditions • Vitamin D Deficiency • Osteoporosis • Obesity • Heart Disease • Hypertension • Diabetes • Thyroid • Cancers • Other medical history • Preventative Care • Primary Care Evaluations

  36. Comprehensive History • Past Multiple Sclerosis (MS) History • Present MS Status • Functional Status • Symptom Review • General Medical Conditions • Social Situation

  37. Social Situation • Living alone or with… • House, apartment, adult family home, assistive living • Number of steps to enter • Stairs in the home • Home modifications • Support Network • Employment • Hobbies • Military Service • Deployment • Service Connection

  38. Social Situation • Tobacco Use • Cigarettes, Cigars • Pipes • Chewing tobacco • Alcohol Use • Daily, Social, Binges • Drug Use • Marijuana • Pills • Cocaine • Heroin • Hallucinogens (LSD, mushrooms, etc)

  39. 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

  40. Questions? Thank You! For more information you can visit the MS Center of Excellence Website: www.va.gov/MS

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