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

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Presentation on theme: "Christina A. Hughes, MD Director, MS Regional Program VA Puget Sound Health Care System Seattle, WA."— Presentation transcript:

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

2 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 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 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 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 Equipment: CPAP machine Cooling Vest Home AC Unit Treatments Medication for fatigue Medication for low thyroid Scheduled Rests Energy Saving Techniques

7 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 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 Past MS History Present MS Status Functional Status Symptom Review General Medical Conditions Social Situation

10 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 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 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 Past Multiple Sclerosis (MS) History Present MS Status Functional Status Symptom Review General Medical Conditions Social Situation

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

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

16 Independent Modified Independent Supervision/Set up Contact Guard Assist Minimal Assist (requires < 25 % help) Moderate Assist (requires % help) Maximum Assist (requires % help) Dependent (requires >75 % help)

17 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 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 Past Multiple Sclerosis (MS) History Present MS Status Functional Status Symptom Review General Medical Conditions Social Situation

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

21 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 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 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 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 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 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 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 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 Characteristics: Depression, PTSD Irritability, Anger Anxiety Suicidal thoughts Treatment: Counseling Optimize Exercise and Social Interaction Medication: SSRI, SSNRI, Tricyclic Antidepressants, Stimulants

30 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 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 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 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 Past Multiple Sclerosis (MS) History Present MS Status Functional Status Symptom Review General Medical Conditions Social Situation

35 Vitamin D Deficiency Osteoporosis Obesity Heart Disease Hypertension Diabetes Thyroid Cancers Other medical history Preventative Care Primary Care Evaluations

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

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

39 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 Thank You! For more information you can visit the MS Center of Excellence Website:


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