Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound Health Care System Seattle, WA.

Christina A. Hughes, MD

Director, MS Regional Program

VA Puget Sound Health Care System

Seattle, WA

What to expect during a Multiple Sclerosis Clinic

Visit- Part 1 -

Personal Medical Journal

Overview of Clinical Comprehensive History

Past MS HistoryPresent MS statusFunctional StatusSymptom ReviewGeneral Medical ConditionsSocial Situation

Recommendations

Outline

Physician Names and contact information

Section for Multiple Sclerosis (MS) diagnosis information

Section for current MS status

Section for documentation of Each MS SymptomPage for characteristics, tests done, equipment usedPage for equipment used and treatmentsPage for current medication and tried/failed

medication

Section for General Medical Conditions


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

ApneaMedical workup: Positive for low thyroidMedical workup: Negative for Depression,

Anemia, Vitamin Deficiencies

Personal Medical Journal Example - Symptom: Fatigue

Equipment:CPAP machineCooling VestHome AC Unit

TreatmentsMedication for fatigueMedication for low thyroidScheduled RestsEnergy Saving Techniques



Current Medication

Amantidine 100 mg twice a dayNo Side Effects

Trialed Medicine

Methylphenidate 5 mg in the morning and 5 mg at noon. Stopped after 2

weeks due to increased anxiety


Overview of Clinical Comprehensive History

Past MS HistoryPresent MS statusFunctional StatusSymptom ReviewGeneral Medical ConditionsSocial Situation

Recommendations

Outline

Past MS History

Present MS Status

Functional Status

Symptom Review

General Medical Conditions

Social Situation

Comprehensive History

DiagnosisWhen diagnosedWho (neurologist, PCP, etc.)How (MRI, Lumbar puncture, symptoms, etc.)What category (Relapsing Remitting, Primary

Progressive, etc)

SymptomsWhen startedWhat was presentation

Past MS History

Past MS HistoryDisease Modifying

Treatment (DMT)What medicationWhen

started/stoppedHow many dosesWhy discontinued

Interferon Beta 1aAvonex, Rebif

Interferon Beta 1bBetaseron, Extavia

Glatiramer Acetate Copaxone

FingolimodGilenya

NatalizumabTysabri

MitoxantroneNovantrone

Methotrexate

Relapse HistoryHow oftenClinical presentationTreatment

MRI When takenWhat part of body (Brain, spine)Where are lesions locatedHow many lesionsWhat other results noted

Past MS History

Past Multiple Sclerosis (MS) History

Present MS Status

Functional Status

Symptom Review


Social Situation


RelapsesHow oftenSymptomsTreatment

Date of last relapseProgressive Neurologic changes

Motor or sensation changes

DMTAdherenceSide Effects

Present MS Status


Present MS Status

Functional Status

Symptom Review


Social Situation


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)

Functional Status

MobilityAssistive Devices

Cane / crutchesWalker / RollatorManual or Power Wheelchair / Scooter

DistanceEquipment

Braces, Functional Electrical Stimulator TransfersFalls (tripping, balance, attention)Home Exercise ProgramMedication

Ampyra

Functional Status

Activities of Daily Living (ADLs)Basic

grooming, toileting, bathing, dressing, eatingInstrumental

finances, shopping, meal prepHome Modifications

Ramp, grab bars, roll-in showerEquipment

Reacher, shower chair, raised toilet seat, Hoyer liftDriving/transportation

Adaptive equipmentAccidents or near accidents

Aide and attendant care

Functional Status


Present MS Status

Functional Status

Symptom Review


Social Situation


Characteristics:Tears, abrasions, pressure ulcerLocationPressure Ulcers

Treatments:OintmentsDressingsDebridementWound VacuumSurgical Intervention – Skin or Muscle Flaps

Symptom Review: Skin

Characteristics:MemoryThought ProcessingConcentrationSpeaking difficulties: Word finding, soft voice

Testing:Neuropsychological Tests

Treatments:Adaptive TechniquesSpeech Language Pathology Therapy

Medication:Memantine, Donepezil, stimulants

Symptom Review: Cognition-Speech

Characteristics:Coughing after liquid or solid intakeGagging or Choking

Testing:Clinic Swallow EvaluationRadiological Swallow Evaluation

Treatments:Modified DietAdaptive TechniquesTube Feeding: PEG or PEJ

Symptom Review: Swallowing

Characteristics:Morning, afternoon, eveningRelieving and worsening factors

Tests:Evaluate current medicationEvaluate SleepEvaluate for DepressionEvaluate for low thyroid, anemia, vitamin deficiency

Treatment:NapsScheduled Rest PeriodsEnergy Saving TechniquesHeat Sensitivity: Cooling Vest, Home, Car Air Conditioning

Medication:Amantadine, Stimulants, Modafinil

Symptom Review: Fatigue

CharacteristicsFalling AsleepStaying Asleep

Nocturia, Pain, Spasticity, NoiseAwakening RefreshedSnoring

Tests:Sleep Studies

Treatment:Adaptive Devices

CPAP, mouth guards, custom bracing/support

Medication:Trazodone, Zolpidem, Benzodiazepines

Symptom Review: Sleep

Characteristics:Arms or legsTightness or jerking motionsWorsening and Relieving FactorsInterferes with… or Helps with…

Treatment:Stretching RegimenBracing

Medication:Baclofen – Oral or Intrathecal PumpTizanidine, Dantrolene, GabapentinBotox Injections

Symptom Review: Spasticity

Characteristics:Hesitancy, Urgency, Frequency, Incontinence,

PainTests:

Evaluate for Urinary Tract InfectionsEvaluate for Retention – Post Void ResidualsEvaluate for Kidney or Bladder Stones

Radiological testing

Treatment:Timed Voids, Double Voids, Crede ManeuverCatheters

Medication:Oxybutynin, Tolterodine, Tamsulosin

Symptom Review: Bladder

Characteristics:Erectile Dysfunction, Low Libido, Pain

Testing:Evaluate hormone levelsEvaluate for Depression

Treatment:Optimizing medical conditionsOptimizing functional limitationsAdaptive equipmentCounseling

Medication:Tadalafil, Sildenafil

Symptom Review: Sexual Concerns

Characteristics:ConstipationDiarrheaIncontinence

Tests:Evaluate Dietary Intake: Fluid, FiberRadiological Testing

Treatment:Consistent Daily Bowel RegimenImprove Diet and Exercise

Medication:Stool Softener, Bulk Forming AgentMotility Agent, Enema

Symptom Review: Bowel

Characteristics:Depression, PTSDIrritability, AngerAnxietySuicidal thoughts

Treatment:CounselingOptimize Exercise and Social Interaction

Medication:SSRI, SSNRI, Tricyclic Antidepressants,

Stimulants

Symptom Review: Mood

Characteristics:Shortness of BreathCoughingPneumoniaMedical Conditions: COPD, Asthma

Testing:Pulmonary Function TestsRadiological Studies

Treatment:Optimize medical conditionsPulmonary RehabilitationAssistive Devices

Medication: Inhaled and oral

Symptom Review: Pulmonary

Characteristics: Blurry vision, Double Vision, Loss of VisionPainDifficulty with tasks (reading, driving, watching

TV)Tests:

Neuro Ophthalmology evaluation yearlyRadiological Studies

Treatment:Prescription lensesAdaptive EquipmentVisual Rehabilitation

Symptom Review: Vision

Characteristics:Where – stationary or radiatingAching, burning, stabbing, tinglingRelieving and Worsening Factors

Testing:Radiological StudiesElectromyography and Nerve Conduction Testing

Treatment:Physical TherapyModalities: Massage, TENS unit, Ultrasound

Medication:Pain ContractTylenol, NSAIDs, Narcotics, Topical InjectionsPain Pumps

Symptom Review: Pain

Characteristics:Numbness, Tingling, Highly sensitive to touchClumsinessLhermittes Sign

Tests:Evaluate for medical conditions like DiabetesNerve Conduction Tests

Treatment:Desensitization Therapies

Medication:Anti-epileptics – Gabapentin, PregabalinTricyclic Antidepressants – Nortriptyline, AmitriptylineSSNRIs – Venlafaxine, Duloxetine

Symptom Review: Sensation


Present MS Status

Functional Status

Symptom Review


Social Situation


Vitamin D DeficiencyOsteoporosisObesityHeart DiseaseHypertensionDiabetesThyroidCancersOther medical historyPreventative CarePrimary Care Evaluations



Present MS Status

Functional Status

Symptom Review


Social Situation


Living alone or with…House, apartment, adult family home, assistive

livingNumber of steps to enterStairs in the homeHome modifications

Support NetworkEmploymentHobbiesMilitary Service

DeploymentService Connection

Social Situation

Tobacco UseCigarettes, CigarsPipesChewing tobacco

Alcohol UseDaily, Social, Binges

Drug UseMarijuanaPillsCocaineHeroinHallucinogens (LSD, mushrooms, etc)

Social Situation

Maintain a Personal Medical JournalBring to every clinic appointment

Past MS History (Diagnosis, Medication, MRI)Past Medical HistoryList of Current Medications

Dosing amount and scheduleList of Past Medication and Reason DiscontinuedList of Questions or ConcernsPaper and Pen to Write Information and

InstructionsVisit an MS Specialist AnnuallyVisit a Primary Care Provider Annually

Recommendations

Thank You!

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

Questions?

Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound Health Care System Seattle, WA.

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Transcript of Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound Health Care System Seattle, WA.