What to expect during a Multiple Sclerosis Clinic Visit - Part 2 -
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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
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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
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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
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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
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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
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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
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Physical Exam - Neurological
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
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Physical Exam - Neurological
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/
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Physical Exam - Neurological
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
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Physical Exam - Neurological
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
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Physical Exam - Neurological
Coordination Balance Fine Motor (fingers) Finger-to-nose Heel-to-shin
http://www.aan.com/go/education/curricula/family/chapter8/section1
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Physical Exam - Neurological
Gait – Base of support, balance, posture, step, stride, rhythm, foot placement, ankle motion, knee motion, hip motion, trunk and pelvis motionhttp://www.rightdiagnosis.com/symptoms/ataxia/book-causes-5c.htm
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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
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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 Passive
http://www.aceproindia.com/ACE%20Sample%20Projects/ePUB/Examination%20and%20Diagnosis%20of%20Musculoskeletal%20Disorders/OEBPS/10_chapter04.html
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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
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Routine Testing Blood Work
Complete blood count (CBC) Chemistry panel Liver function tests Vitamins D and B12 Thyroid function cholesterol hemoglobin A1C
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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
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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
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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
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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
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Routine Testing Pulmonology
Pulmonary Function Tests
DEXA Scan
http://www.qcradiology.com/bone_dens.html
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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
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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
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Specialty Testing Electromyography (EMG)
Measures electrical activity of the muscles Nerve Conduction Studies (NCS)
Measures nerve health
http://painmd.tv/electrodiagnostics/
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Outline Physical Exam
Neurological Exam Musculoskeletal Exam
Routine Testing Blood Work Radiology Pulmonology Ophthalmology
Specialty Testing EMG/ NCS – Electromyography / Nerve Conduction
Studies Radiology Other
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Specialty Testing Radiology
Plain X-rays Renal Ultrasound Venous and arterial Ultrasound CT-scan MRI Thoracic Spine MRI Lumbar Spine
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Outline Physical Exam
Neurological Exam Musculoskeletal Exam
Routine Testing Blood Work Radiology Pulmonology Ophthalmology
Specialty Testing EMG/ NCS – Electromyography / Nerve Conduction
Studies Radiology Other
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Specialty Testing Swallow Evaluation
Bedside Video-fluoroscopic swallow study with barium
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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
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Thank You!
For more information you can visit the MS Center of Excellence Website: www.va.gov/MS
Questions?