What to expect during a Multiple Sclerosis Clinic Visit - Part 2 -

1. What to expect during a Multiple Sclerosis Clinic Visit- Part 2 - Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound Health Care System Seattle, WA

2. Review from Past lecture MS Clinic Visit – Part 1 • 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. 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

4. 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

5. 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

6. 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

7. 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 12 http://apbrwww5.apsu.edu/thompsonj/Anatomy%20&%20Physiology/2010/2010%20Exam%20Reviews/Exam%204%20Review/CH%2013%20Peripheral%20Nerve%20Terminology.htm

8. 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/

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

10. 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

11. Physical Exam - Neurological • Coordination • Balance • Fine Motor (fingers) • Finger-to-nose • Heel-to-shin http://www.aan.com/go/education/curricula/family/chapter8/section1

12. Physical Exam - Neurological • 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

13. 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

14. 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

15. 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

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

17. 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

18. 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

19. MRI Scans of the Brain of a 25-Year-Old Woman with Relapsing-Remitting Multiple Sclerosis Noseworthy J et al. N Engl J Med 2000;343:938-952

20. 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

21. Routine Testing • Pulmonology • Pulmonary Function Tests • DEXA Scan http://www.qcradiology.com/bone_dens.html

22. Routine Testing • Ophthalmology • Optical Coherence Tomography • Non invasive (done in the clinic) • Measures the retinal nerve thickness Optical coherence tomography findings in acute macular neuroretinopathy D Shukla, A Arora, S Ambatkar, K Ramasamy and N Perumalsamy http://www.nature.com/eye/journal/v19/n1/fig_tab/6701414f1.html

23. 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

24. Specialty Testing • Electromyography (EMG) • Measures electrical activity of the muscles • Nerve Conduction Studies (NCS) • Measures nerve health http://painmd.tv/electrodiagnostics/

25. Outline • Physical Exam • Neurological Exam • Musculoskeletal Exam • Routine Testing • Blood Work • Radiology • Pulmonology • Ophthalmology • Specialty Testing • EMG/ NCS – Electromyography / Nerve Conduction Studies • Radiology • Other

26. Specialty Testing • Radiology • Plain X-rays • Renal Ultrasound • Venous and arterial Ultrasound • CT-scan • MRI Thoracic Spine • MRI Lumbar Spine

27. Outline • Physical Exam • Neurological Exam • Musculoskeletal Exam • Routine Testing • Blood Work • Radiology • Pulmonology • Ophthalmology • Specialty Testing • EMG/ NCS – Electromyography / Nerve Conduction Studies • Radiology • Other

28. Specialty Testing • Swallow Evaluation • Bedside • Video-fluoroscopic swallow study with barium

29. 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

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