The Follow-up Exam - What's yours consist of?
What does your personal follow-up exam consist of? And, can you include if you are dx'd or not? The frequency, etc.
Mine look like this:
Frequency: 3 months
-Question and answer discuss current goings on
-Exam: sit on edge of table, lift knees checks strength (I think)
hold up arms while Dr. presses down, spread out fingers while Dr. squeezes them in
-Eyes: follow the finger, touch the finger, count how many fingers are up and checks with light
-Stand with eyes closed momentarily and then walk heel to toe
Think that abour covers it! Says on the paper it's a level 4 fyi.
I am recently diagnosed. My first f/u appointment is scheduled for August. Doc mentioned ordering more MRIs then. My first appointment was 2.5 hours long. The physical/neuro exam couldn't have lasted more than 10-15 minutes of that. I'm afraid this doc is a lesion counter and relies on lab info far more than his own exam for evaluation.
The exam I had at the initial visit was much as you described above. Additionally, I was asked to walk the hall. NO neuro has ever asked me to do any balance test with closed eyes or a heel-toe walk. Interesting since so many of you have mentioned that one and I don't even have the guts to try that one at home.
Interesting question! I hope you get lots of responses.
Mine is almost identical to yours, including the mini neuro exam. I do usually have an extended Q&A period where my neuro will sit and talk with me until I'm satisfied with no sense of urgency to get to the next patient.
Had my 6-month Rebif followup yesterday.
Same exam as yours pretty much, but also did eye chart and walked up & down the hall. Nurse did look at injection sites too.
I see neuro every 6 months, and his nurse pract. every 6 months -- alternating,so they're separated by 3 months. Nurse does a much better job, and knows pretty much everything there is to know about MS -- she's the only reason I stay with that neuro.
(BTW, she thinks laquinomod, likely available 2012, will be the only really safe & effective Oral DMD in the near future.)
My last neuro appt with the neuro I fired was a sham. He asked questions, barely making eye contact with me, and discounted every symptom I tried to tell him about.
My wife and I were very dissapointed and decided not to return to this jackass.
I went to my GP for a follow up and he had recieved a 2 page report from the useless neuro listing his findings after examining me. Examining me!!!! He barely listened to me and did not examine me at all!
My new neuro spent at least an hour with me and did a fairly in depth examination much like you describe. He also ordered a pile new tests. His report to my GP was acurate. (he didn't have to make things up like neuro #1)
I think my pain pills are kicking in (got a bad headache) I feel like I'm babbling here.
Every six months, basic neuro exam, I am asked what bothers me most and am sent on my way. It takes about 15 minutes. It is basically monitoring. I had my last MRI February 2009 and will have another August 2010.
Thirty minutes or longer taking my history, asking questions and listening to what I had to say and answering my questions.
Entire appointment took about an hour and half, perhaps even longer.
The examination was;
Walk heel to toe
Stand eyes shut with legs together, eyes shut with arms out or maybe eyes are open
light in eye, follow his finger with eyes, brushing something against both sides of face to feel differences, having to smile, poke tongue out, puff cheeks out etc.
touch my nose and then touch his finger as he moves it
action like turning taps on and off
tuning fork on feet and legs i think, the vibration thinngy
hit me with his hammer both legs and arms
flicking my ankle back to check clonus ( i think)
strength tests like shell described
then he uses something to test my sensation on my legs, back, stomach etc. and I have to say when I can feel it more.
He pulls the end of my fingers for some reason, like holds them in his fingers and pulls them
My subsequent visits have been between 6mths and 3mths apart. My neurologist has diagnosed me with Transverse Myelitis ( I have no lesions to be seen), nothing even to question, but my exam is abnormal. He thinks I am stable and that some of my other problems are migraine as well as the damage from the TM. He seems definite that I have a cord lesion although it can't be seen.
I think this visit he might say only come back if it gets worse as I seem to be stable, although I get symptoms I am now thinking this is migraine. He has done 3 MRI in two years, but only one brain MRI, which was my first one.
My latest exams seem to be the same as the first one but he seems to concentrate on strength, balance, and babinski, and my reflexes, he hasn't made me do the face thing again but he always checks my eyes.
I see him on Monday and I like him, he is a MS Specialist.
Follow-up?? I was diagnosed 6 months ago, started Copaxone 4 months ago and have no plans to see the neurologist again. I mentioned repeating an MRI down the road but the nurse said it'd be too expensive and not worth it.
My initial exams in late 2008 and early 2009 were pretty thorough, including pinprick, cotton ball, vibration, etc. My more recent exams were pretty brief, including reflexes, gait, walking heel to toe, on heels only, on toes only. These take 15 minutes, and I tend to come in with my complaints and questions written down so I don't forget to ask.
My next appt. is in May (3 month f/u after 1st infusion of Tysabri), and needs to be at least every 6 mo. while I'm on Tysabri.
I'm curious about getting a 2nd set of MRIs this spring to see if lesion activity has changed. My neuro has no problem with this.
I just saw my neuro last week so good timing for your question as his exam is still fresh in my mind.
Appts are typically 90 mins to 2 hrs.
First we have a lengthy discussion about my ongoing symptoms, any concerns, review of my medications and supplements, asks about how my injections are going, and how my MS is impacting my daily life.
Usually we'll have some discussion about various trials including ones he is leading; I am always hopeful to be able to participate but frequency of visits usually rules this out as I live a 4.5 hr drive from this MS clinic.
This time I had lots of questions about CCSVI and his view. Will comment about that in a separate post.
He then does a lengthy exam as per below. After he is done, I ask him what he is noticing, instead of waiting to read his report as I used to do. This time he told me he didn't see much change from my last exam which he said was encouraging. He described my current status as 'stable.'
He then writes up any prescriptions I need - this time it was annual renewal of Copaxone. I then meet with his nurse, who has me sign the application form to continue my DMD coverage, then checks my injection sites and I'm on my way.
This neuro's demeanor is pleasant and not intimidating or arrogant, though he is still fairly formal considering I've seen him a number of times now. He always shakes my hand and the start and end of the appt. When my husband is with me in the waiting room, he always invites him in. He doesn't call me by my first name, but addresses me directly and about me as "Ms. [last name]."
He takes no notes while I'm there but repeats and paraphrases my comments several times so I know he is listening. He doesn't seem to mind when I need to correct him.
re: frequency, since my first appt with him when I was dx'ed in Nov 2007, I have seen him about every 5 months on average. Lots going on in my first couple of years with MS; 3 relapses in just over one year; change in DMD; testing for NMO a year after MS dx; etc. Things have been quiet since Dec 2008, and my neuro exam this time was non-eventful, so this time he said he doesn't need to see me for a year unless things take a turn for the worse in the meantime.
So....back to your original question! My exam consists of the following, though this is not in the order he does it:
checks 'rapidly alternating movement' which is where, while sitting up, I place my hands palm side down on my thighs, then turn them over so the back of my hand is flat on my thighs, then repeat several times very quickly
rapidly touch each finger to thumb on same hand, several times in both hands
touch my finger to his finger then my nose, back and forth, several times, quickly
brisk walk down hall
tandem gait (heel to toe walking)
Rhomberg (stand with eyes closed)
pin ***** on each leg and hand, compare sensation
metal disk on each hand for temperature sensation, does it feel cold on both hands
position sense in toes where I close my eyes as he moves my toes and I tell him if I think he moved it up or down
lay down, run heel up and down opposite shin several times
hold arms straight out, palms up, and resist against him pushing down hard on both arms
he grips my wrist, I push against his grip
I squeeze his finger as tightly as possible
lay down, lift leg straight up, resist against him pushing down on my leg
sitting up, loosen my arm and he grabs it and sort of flops it around
laying down, loosen my leg and he flops it around
tests reflex at elbows, wrists and knees
follow his finger with my eyes
checks pupils with light
read tiny letters on a card that I hold away from me at arm's length
looking straight at him, tell him how many fingers I see him holding up in my peripheral vision
stick out tongue
tuning fork against each foot, and tell him when vibration stops
Your have just described my neuro exam to a T. That is exactly what I have to do every time I go apart from the tongue poking out, he only made me do that the first visit. My neuro makes me do lots of alternating movement things too. Why do they do that?
My neuro always refers to me by my first name which I prefer, seems to be more casual but still professional. I am not sure if on Monday he will order another MRI or if he will leave it, I guess it depends if he thinks I am stable or if I have progressed.
Interesting the differences in exams and neuro's. My neurologist does not get his nurses to do any of the questioning or the exam.
All my subesquent visits have taken between an hour to 45 minutes.
My follow up exams were every 3 mos for the first two years and have now been stretched out to every 4 months - even though my status isn't changing much. MRIs were done yearly for the first two years, but now will likely not be done unless my exam or disability changes dramatically.
The visit takes a minimum of an hour and a half.
First, there is a detailed Q and A on how things are going done by the doctor himself.
The exam goes like this:
Full cranial nerve assessment except smell:
pupils with and w/o swinging light
facial expression strength
shrugging and neck strength
sensation on face
Nose to his finger with a few variations of this
Full tendon reflexes - each repeated several times
Check for ankle clonus
Quick sharp sensation over all limbs and torso
18 pairs of muscles checked each time and compared to prior exams
Stand with extended arms with eyes closed (Romberg's)
Rapidly alternating hand and finger movements
Timed 25 ft. walk (always using same parameters as before. Right now without cane)
These are done EVERY visit and I am told what has changed from prior exams. They care what has changed.
Then another meeting to discuss their thoughts and current plan.
They can monitor all changes and I can see that what I feel are worsenings are barely different from previous visits. Because, in truth, I always feel bad and always feel that I am worsening. This keeps it in perspective.
Initially I was seen every three months and then out to 4 months - the depression meds were started and he did a followup sooner to see if those were good. The followup appts were about 45 minutes and involved more talk than exam. My last appt. which was to review my annual MRI was about an hour.
The MS nurse did my neuro exam while the doctor talked to me about symptoms and he took the notes from her exam. Interesting role reversal, huh? But he's that kind of guy. It was the usual conplete exam. There is always a student present, too. I am asked permission to have the extra person sit in, of course.
The exam covers all the things Q has done at hers. It really doesn't take long to go through that list if the person doing it is skilled.
When I was heading to the exam room, he first gave me a hug - I had just told him I was grumpy about having to drive further to their new location. And I really was grouchy. He surprised me at the end of the exam when he bent over to where I was sitting and gave me another hug goodbye and encouraged me to get over the grumpiness. My DH was present for all of this - they always encourage him to sit in on the appt. if he's along. I don't know if the hugs will continue because I'm *special* or if that was a one time deal because I was out of sorts and he could immediately tell I was aggitated. We do have a good, easy and relaxed rapport.
He gave me the option of returning in 4 to six months. I opted for six months because it is a bit of a drive since they moved their office - almost 2 hours. If something else comes up before then, I can always get in to see him sooner.
After my first neuro visit ever, i was curious and read what other people were saying about their testing, one thing was clear, i'd probably had one of the shortest first appt on record, 10 to 15 minutes tops. It still showed their was something neurological happening but i wanted to understand what each test was looking for, interestingly i came across a book called 'The 4 minute neurological exam' and another for 15 minutes, it seems neurologist are shortening the exam to its exstreem, and i'm still wondering why.
The follow up appt would of only lasted a few seconds if i hadn't annoyed him by asking questions and sitting down in the chair, the only time he even looked at me was when he told me i wasn't allowed to ever have a friday afternoon appointment again, the rest of the time he was looking at his computer screen, saying illogical explanations to my Q's and throwing sarcastic comments when i queeried what he was saying, it was very unpleasant and the biggest reason i'm very reluctant to repeat the experience again.
Thank you all for sharing! I'm hoping to put together something on this real soon.
It's safe to say that the overwhelming majority of members who provided comment on follow-up appointments receive bare bones on follow up.
If you look at Doc Q's visits, you can see what is not checked. Please do this...cranial nerve assessments, facial checks, 18 muscle group, reflexes! Is that too much to ask? These are the common areas affected that cause us problems and affect our everyday lives. They should be followed.
Thank you all once again. Hoping to gather more information for a health page.
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