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
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
Personal Medical Journal
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
Personal Medical Journal Example - Symptom: Fatigue
Personal Medical Journal Example - Symptom: Fatigue
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
Personal Medical Journal
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
General Medical Conditions
Social Situation
Comprehensive History
RelapsesHow oftenSymptomsTreatment
Date of last relapseProgressive Neurologic changes
Motor or sensation changes
DMTAdherenceSide Effects
Present MS Status
Past Multiple Sclerosis (MS) History
Present MS Status
Functional Status
Symptom Review
General Medical Conditions
Social Situation
Comprehensive History
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
Past Multiple Sclerosis (MS) History
Present MS Status
Functional Status
Symptom Review
General Medical Conditions
Social Situation
Comprehensive History
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
Past Multiple Sclerosis (MS) History
Present MS Status
Functional Status
Symptom Review
General Medical Conditions
Social Situation
Comprehensive History
Vitamin D DeficiencyOsteoporosisObesityHeart DiseaseHypertensionDiabetesThyroidCancersOther medical historyPreventative CarePrimary Care Evaluations
General Medical Conditions
Past Multiple Sclerosis (MS) History
Present MS Status
Functional Status
Symptom Review
General Medical Conditions
Social Situation
Comprehensive History
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?
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