VA Puget Sound Health Care System

quietplumAI and Robotics

Feb 23, 2014 (3 years and 7 months ago)

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Christina A. Hughes, MD

Director, MS Regional Program

VA Puget Sound Health Care System

Seattle, WA


Personal Medical Journal


Overview of Clinical Comprehensive History


Past MS History


Present MS status


Functional Status


Symptom Review


General Medical Conditions


Social Situation


Recommendations


Personal Medical Journal


Overview of Clinical Comprehensive History


Past MS History


Present MS status


Functional Status


Symptom Review


General Medical Conditions


Social Situation


Recommendations


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


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



Equipment:


CPAP machine


Cooling Vest


Home AC Unit



Treatments


Medication for fatigue


Medication for low thyroid


Scheduled Rests


Energy Saving Techniques

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


Personal Medical Journal


Overview of Clinical Comprehensive History


Past MS History


Present MS status


Functional Status


Symptom Review


General Medical Conditions


Social Situation


Recommendations


Past MS History



Present MS Status



Functional Status



Symptom Review



General Medical Conditions



Social Situation




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


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



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


Past Multiple Sclerosis (MS) History



Present MS Status



Functional Status



Symptom Review



General Medical Conditions



Social Situation




Relapses


How often


Symptoms


Treatment


Date of last relapse


Progressive Neurologic changes


Motor or sensation changes


DMT


Adherence


Side Effects


Past Multiple Sclerosis (MS) History



Present MS Status



Functional Status



Symptom Review



General Medical Conditions



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)


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


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



Past Multiple Sclerosis (MS) History



Present MS Status



Functional Status



Symptom Review



General Medical Conditions



Social Situation




Characteristics:


Tears, abrasions, pressure ulcer


Location


Pressure Ulcers



Treatments:


Ointments


Dressings


Debridement


Wound Vacuum


Surgical Intervention


Skin or Muscle Flaps


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


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


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


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




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


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




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


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


Characteristics:


Depression, PTSD


Irritability, Anger


Anxiety


Suicidal thoughts


Treatment:


Counseling


Optimize Exercise and Social Interaction


Medication:


SSRI, SSNRI, Tricyclic Antidepressants, Stimulants


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


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


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



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


Past Multiple Sclerosis (MS) History



Present MS Status



Functional Status



Symptom Review



General Medical Conditions



Social Situation




Vitamin D Deficiency


Osteoporosis


Obesity


Heart Disease


Hypertension


Diabetes


Thyroid


Cancers


Other medical history


Preventative Care


Primary Care Evaluations


Past Multiple Sclerosis (MS) History



Present MS Status



Functional Status



Symptom Review



General Medical Conditions



Social Situation




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



Tobacco Use


Cigarettes, Cigars


Pipes


Chewing tobacco


Alcohol Use


Daily, Social, Binges


Drug Use


Marijuana


Pills


Cocaine


Heroin


Hallucinogens (LSD, mushrooms, etc)



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

Thank You!


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