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 Review from Past lecture MS Clinic Visit – Part 1

3. 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

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%20Re views/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. 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

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