Embed Size (px)
Citation preview
EEPPEECC
EEPPEECC
Common Physical Symptoms
Common Physical Symptoms
Module 10Module 10Module 10Module 10
The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation
The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation
ObjectivesObjectives
Know general guidelines for Know general guidelines for managing nonpain symptomsmanaging nonpain symptoms
Understand how the principles of Understand how the principles of intended / unintended consequences intended / unintended consequences and double effect apply to symptom and double effect apply to symptom managementmanagement
Know the assessment, management Know the assessment, management of common physical symptomsof common physical symptoms
Know general guidelines for Know general guidelines for managing nonpain symptomsmanaging nonpain symptoms
Understand how the principles of Understand how the principles of intended / unintended consequences intended / unintended consequences and double effect apply to symptom and double effect apply to symptom managementmanagement
Know the assessment, management Know the assessment, management of common physical symptomsof common physical symptoms
General management guidelines . . .General management guidelines . . . History, physical examinationHistory, physical examination
Conceptualize likely causesConceptualize likely causes
Discuss treatment options, assist Discuss treatment options, assist with decision makingwith decision making
History, physical examinationHistory, physical examination
Conceptualize likely causesConceptualize likely causes
Discuss treatment options, assist Discuss treatment options, assist with decision makingwith decision making
. . . General management guidelines. . . General management guidelines Provide ongoing patient, family Provide ongoing patient, family
education, supporteducation, support
Involve members of the entire Involve members of the entire interdisciplinary teaminterdisciplinary team
Reassess frequentlyReassess frequently
Provide ongoing patient, family Provide ongoing patient, family education, supporteducation, support
Involve members of the entire Involve members of the entire interdisciplinary teaminterdisciplinary team
Reassess frequentlyReassess frequently
Intended vs unintended consequencesIntended vs unintended consequences Primary intent dictates ethical Primary intent dictates ethical
medical practicemedical practice
Primary intent dictates ethical Primary intent dictates ethical medical practicemedical practice
Breathlessness (dyspnea) . . .Breathlessness (dyspnea) . . . May be described asMay be described as
shortness of breathshortness of breath
a smothering feelinga smothering feeling
inability to get enough airinability to get enough air
suffocationsuffocation
May be described asMay be described as
shortness of breathshortness of breath
a smothering feelinga smothering feeling
inability to get enough airinability to get enough air
suffocationsuffocation
. . . Breathlessness (dyspnea). . . Breathlessness (dyspnea) The only reliable measure is patient The only reliable measure is patient
self-reportself-report
Respiratory rate, pORespiratory rate, pO22, blood gas , blood gas
determinations DO NOT correlate determinations DO NOT correlate with the feeling of breathlessnesswith the feeling of breathlessness
Prevalence in the life-threateningly Prevalence in the life-threateningly ill: 12 – 74%ill: 12 – 74%
The only reliable measure is patient The only reliable measure is patient self-reportself-report
Respiratory rate, pORespiratory rate, pO22, blood gas , blood gas
determinations DO NOT correlate determinations DO NOT correlate with the feeling of breathlessnesswith the feeling of breathlessness
Prevalence in the life-threateningly Prevalence in the life-threateningly ill: 12 – 74%ill: 12 – 74%
Causes of breathlessnessCauses of breathlessness
AnxietyAnxiety
Airway obstructionAirway obstruction
BronchospasmBronchospasm
HypoxemiaHypoxemia
Pleural effusionPleural effusion
PneumoniaPneumonia
Pulmonary edemaPulmonary edema
AnxietyAnxiety
Airway obstructionAirway obstruction
BronchospasmBronchospasm
HypoxemiaHypoxemia
Pleural effusionPleural effusion
PneumoniaPneumonia
Pulmonary edemaPulmonary edema
Pulmonary Pulmonary embolismembolism
Thick secretionsThick secretions
AnemiaAnemia
MetabolicMetabolic
Family / financial / Family / financial / legal / spiritual / legal / spiritual / practical issuespractical issues
Pulmonary Pulmonary embolismembolism
Thick secretionsThick secretions
AnemiaAnemia
MetabolicMetabolic
Family / financial / Family / financial / legal / spiritual / legal / spiritual / practical issuespractical issues
Managementof breathlessnessManagementof breathlessness Treat the underlying causeTreat the underlying cause
Symptomatic managementSymptomatic management
oxygenoxygen
opioidsopioids
anxiolyticsanxiolytics
nonpharmacologic interventionsnonpharmacologic interventions
Treat the underlying causeTreat the underlying cause
Symptomatic managementSymptomatic management
oxygenoxygen
opioidsopioids
anxiolyticsanxiolytics
nonpharmacologic interventionsnonpharmacologic interventions
OxygenOxygen
Pulse oximetry not helpfulPulse oximetry not helpful
Potent symbol of medical carePotent symbol of medical care
ExpensiveExpensive
Fan may do just as wellFan may do just as well
Pulse oximetry not helpfulPulse oximetry not helpful
Potent symbol of medical carePotent symbol of medical care
ExpensiveExpensive
Fan may do just as wellFan may do just as well
OpioidsOpioids
Relief not related to respiratory rateRelief not related to respiratory rate
No ethical or professional barriersNo ethical or professional barriers
Small dosesSmall doses
Central and peripheral actionCentral and peripheral action
Relief not related to respiratory rateRelief not related to respiratory rate
No ethical or professional barriersNo ethical or professional barriers
Small dosesSmall doses
Central and peripheral actionCentral and peripheral action
AnxiolyticsAnxiolytics
Safe in combination with opioidsSafe in combination with opioids
lorazepamlorazepam
0.5-2 mg po q 1 h prn until 0.5-2 mg po q 1 h prn until settledsettled
then dose routinely q 4–6 h to then dose routinely q 4–6 h to keep settledkeep settled
Safe in combination with opioidsSafe in combination with opioids
lorazepamlorazepam
0.5-2 mg po q 1 h prn until 0.5-2 mg po q 1 h prn until settledsettled
then dose routinely q 4–6 h to then dose routinely q 4–6 h to keep settledkeep settled
Nonpharmacologic interventions . . .Nonpharmacologic interventions . . . Reassure, work to manage anxietyReassure, work to manage anxiety
Behavioral approaches, eg, Behavioral approaches, eg, relaxation, distraction, hypnosisrelaxation, distraction, hypnosis
Limit the number of people in the Limit the number of people in the roomroom
Open windowOpen window
Reassure, work to manage anxietyReassure, work to manage anxiety
Behavioral approaches, eg, Behavioral approaches, eg, relaxation, distraction, hypnosisrelaxation, distraction, hypnosis
Limit the number of people in the Limit the number of people in the roomroom
Open windowOpen window
Nonpharmacologic interventions . . .Nonpharmacologic interventions . . . Eliminate environmental irritantsEliminate environmental irritants
Keep line of sight clear to outside Keep line of sight clear to outside
Reduce the room temperatureReduce the room temperature
Avoid chilling the patientAvoid chilling the patient
Eliminate environmental irritantsEliminate environmental irritants
Keep line of sight clear to outside Keep line of sight clear to outside
Reduce the room temperatureReduce the room temperature
Avoid chilling the patientAvoid chilling the patient
. . . Nonpharmacologic interventions. . . Nonpharmacologic interventions Introduce humidityIntroduce humidity
RepositionReposition
elevate the head of the bedelevate the head of the bed
move patient to one side or othermove patient to one side or other
Educate, support the familyEducate, support the family
Introduce humidityIntroduce humidity
RepositionReposition
elevate the head of the bedelevate the head of the bed
move patient to one side or othermove patient to one side or other
Educate, support the familyEducate, support the family
Nausea / vomitingNausea / vomiting
Nausea Nausea
subjective sensationsubjective sensation
stimulation stimulation
gastrointestinal lining, CTZ, gastrointestinal lining, CTZ, vestibular apparatus, cerebral vestibular apparatus, cerebral cortexcortex
VomitingVomiting
neuromuscular reflexneuromuscular reflex
Nausea Nausea
subjective sensationsubjective sensation
stimulation stimulation
gastrointestinal lining, CTZ, gastrointestinal lining, CTZ, vestibular apparatus, cerebral vestibular apparatus, cerebral cortexcortex
VomitingVomiting
neuromuscular reflexneuromuscular reflex
Causesof nausea / vomitingCausesof nausea / vomiting MMetastasesetastases
MMeningeal eningeal irritationirritation
MMovementovement
MMental anxietyental anxiety
MMedicationsedications
MMucosal irritationucosal irritation
MMetastasesetastases
MMeningeal eningeal irritationirritation
MMovementovement
MMental anxietyental anxiety
MMedicationsedications
MMucosal irritationucosal irritation
MMechanical echanical obstructionobstruction
MMotilityotility
MMetabolicetabolic
MMicrobesicrobes
MMyocardialyocardial
MMechanical echanical obstructionobstruction
MMotilityotility
MMetabolicetabolic
MMicrobesicrobes
MMyocardialyocardial
Pathophysiologyof nausea / vomitingPathophysiologyof nausea / vomiting
CortexCortexCortexCortex
Vestibular Vestibular apparatusapparatusVestibular Vestibular apparatusapparatus
GI tractGI tractGI tractGI tract
ChemoreceptorChemoreceptorTrigger Zone (CTZ)Trigger Zone (CTZ)
ChemoreceptorChemoreceptorTrigger Zone (CTZ)Trigger Zone (CTZ)
NeurotransmittersNeurotransmitters SerotoninSerotonin DopamineDopamine AcetylcholineAcetylcholine HistamineHistamine
NeurotransmittersNeurotransmitters SerotoninSerotonin DopamineDopamine AcetylcholineAcetylcholine HistamineHistamine
Vomiting centerVomiting center
Managementof nausea / vomitingManagementof nausea / vomiting Dopamine Dopamine
antagonistsantagonists
AntihistaminesAntihistamines
AnticholinergicsAnticholinergics
Serotonin Serotonin antagonistsantagonists
Dopamine Dopamine antagonistsantagonists
AntihistaminesAntihistamines
AnticholinergicsAnticholinergics
Serotonin Serotonin antagonistsantagonists
Prokinetic agentsProkinetic agents
AntacidsAntacids
Cytoprotective Cytoprotective agentsagents
Other medicationsOther medications
Prokinetic agentsProkinetic agents
AntacidsAntacids
Cytoprotective Cytoprotective agentsagents
Other medicationsOther medications
Dopamine antagonistsDopamine antagonists HaloperidolHaloperidol ProchlorperazineProchlorperazine Droperidol Droperidol ThiethylperazineThiethylperazine Promethazine Promethazine Perphenazine Perphenazine TrimethobenzamideTrimethobenzamide MetoclopramideMetoclopramide
HaloperidolHaloperidol ProchlorperazineProchlorperazine Droperidol Droperidol ThiethylperazineThiethylperazine Promethazine Promethazine Perphenazine Perphenazine TrimethobenzamideTrimethobenzamide MetoclopramideMetoclopramide
Histamine antagonists (antihistamines)Histamine antagonists (antihistamines)
DiphenhydramineDiphenhydramine
MeclizineMeclizine
HydroxyzineHydroxyzine
DiphenhydramineDiphenhydramine
MeclizineMeclizine
HydroxyzineHydroxyzine
Acetylcholine antagonists(anticholinergics)Acetylcholine antagonists(anticholinergics)
ScopolamineScopolamine ScopolamineScopolamine
Serotonin antagonistsSerotonin antagonists
OndansetronOndansetron
GranisetronGranisetron
OndansetronOndansetron
GranisetronGranisetron
Prokinetic agentsProkinetic agents
MetoclopramideMetoclopramide
CisaprideCisapride
MetoclopramideMetoclopramide
CisaprideCisapride
AntacidsAntacids AntacidsAntacids
HH22 receptor antagonists receptor antagonists
cimetidinecimetidine
famotidinefamotidine
ranitidineranitidine
Proton pump inhibitorsProton pump inhibitorsomeprazoleomeprazole
lansoprazolelansoprazole
AntacidsAntacids
HH22 receptor antagonists receptor antagonists
cimetidinecimetidine
famotidinefamotidine
ranitidineranitidine
Proton pump inhibitorsProton pump inhibitorsomeprazoleomeprazole
lansoprazolelansoprazole
Cytoprotective agentsCytoprotective agents
MisoprostolMisoprostol
Proton pump inhibitors (omeprazole, Proton pump inhibitors (omeprazole, lansoprazole)lansoprazole)
MisoprostolMisoprostol
Proton pump inhibitors (omeprazole, Proton pump inhibitors (omeprazole, lansoprazole)lansoprazole)
Other medicationsOther medications
DexamethasoneDexamethasone
TetrahydrocannabinolTetrahydrocannabinol
LorazepamLorazepam
OctreotideOctreotide
DexamethasoneDexamethasone
TetrahydrocannabinolTetrahydrocannabinol
LorazepamLorazepam
OctreotideOctreotide
ConstipationConstipation MedicationsMedications
opioidsopioids
calcium-channel calcium-channel blockersblockers
anticholinergicanticholinergic
Decreased motilityDecreased motility
IleusIleus
Mechanical Mechanical obstructionobstruction
MedicationsMedications
opioidsopioids
calcium-channel calcium-channel blockersblockers
anticholinergicanticholinergic
Decreased motilityDecreased motility
IleusIleus
Mechanical Mechanical obstructionobstruction
Metabolic Metabolic abnormalitiesabnormalities
Spinal cord Spinal cord compressioncompression
DehydrationDehydration
Autonomic Autonomic dysfunctiondysfunction
MalignancyMalignancy
Metabolic Metabolic abnormalitiesabnormalities
Spinal cord Spinal cord compressioncompression
DehydrationDehydration
Autonomic Autonomic dysfunctiondysfunction
MalignancyMalignancy
Managementof constipationManagementof constipation General measuresGeneral measures
establish what is establish what is “normal”“normal”
regular toiletingregular toileting
gastrocolic reflexgastrocolic reflex
General measuresGeneral measures
establish what is establish what is “normal”“normal”
regular toiletingregular toileting
gastrocolic reflexgastrocolic reflex
Specific measuresSpecific measures
stimulantsstimulants
osmoticsosmotics
detergentsdetergents
lubricantslubricants
large volume large volume enemasenemas
Specific measuresSpecific measures
stimulantsstimulants
osmoticsosmotics
detergentsdetergents
lubricantslubricants
large volume large volume enemasenemas
Stimulant laxativesStimulant laxatives
Prune juice Prune juice
Senna Senna
Casanthranol Casanthranol
BisacodylBisacodyl
Prune juice Prune juice
Senna Senna
Casanthranol Casanthranol
BisacodylBisacodyl
Osmotic laxativesOsmotic laxatives
Lactulose or sorbitol Lactulose or sorbitol
Milk of magnesia (other Mg salts) Milk of magnesia (other Mg salts)
Magnesium citrateMagnesium citrate
Lactulose or sorbitol Lactulose or sorbitol
Milk of magnesia (other Mg salts) Milk of magnesia (other Mg salts)
Magnesium citrateMagnesium citrate
Detergent laxatives(stool softeners)Detergent laxatives(stool softeners)
Sodium docusateSodium docusate
Calcium docusateCalcium docusate
Phosphosoda enema prnPhosphosoda enema prn
Sodium docusateSodium docusate
Calcium docusateCalcium docusate
Phosphosoda enema prnPhosphosoda enema prn
Prokinetic agentsProkinetic agents
Metoclopramide Metoclopramide
Cisapride Cisapride
Metoclopramide Metoclopramide
Cisapride Cisapride
Lubricant stimulantsLubricant stimulants
Glycerin suppositoriesGlycerin suppositories
OilsOils
mineralmineral
peanutpeanut
Glycerin suppositoriesGlycerin suppositories
OilsOils
mineralmineral
peanutpeanut
Large-volume enemasLarge-volume enemas
Warm waterWarm water
Soap sudsSoap suds
Warm waterWarm water
Soap sudsSoap suds
Constipationfrom opioids . . .Constipationfrom opioids . . . Occurs with all opioidsOccurs with all opioids
Pharmacologic tolerance developed Pharmacologic tolerance developed slowly, or not at allslowly, or not at all
Dietary interventions alone usually Dietary interventions alone usually not sufficientnot sufficient
Avoid bulk-forming agents in Avoid bulk-forming agents in debilitated patientsdebilitated patients
Occurs with all opioidsOccurs with all opioids
Pharmacologic tolerance developed Pharmacologic tolerance developed slowly, or not at allslowly, or not at all
Dietary interventions alone usually Dietary interventions alone usually not sufficientnot sufficient
Avoid bulk-forming agents in Avoid bulk-forming agents in debilitated patientsdebilitated patients
. . . Constipationfrom opioids. . . Constipationfrom opioids Combination stimulant / softeners Combination stimulant / softeners
are useful first-line medicationsare useful first-line medications
casanthranol + docusate sodiumcasanthranol + docusate sodium
senna + docusate sodiumsenna + docusate sodium
Prokinetic agentsProkinetic agents
Combination stimulant / softeners Combination stimulant / softeners are useful first-line medicationsare useful first-line medications
casanthranol + docusate sodiumcasanthranol + docusate sodium
senna + docusate sodiumsenna + docusate sodium
Prokinetic agentsProkinetic agents
Causes of diarrheaCauses of diarrhea InfectionsInfections GI bleedingGI bleeding MalabsorptionMalabsorption MedicationsMedications ObstructionObstruction Overflow incontinenceOverflow incontinence StressStress
InfectionsInfections GI bleedingGI bleeding MalabsorptionMalabsorption MedicationsMedications ObstructionObstruction Overflow incontinenceOverflow incontinence StressStress
Management of diarrheaManagement of diarrhea
Establish normal bowel patternEstablish normal bowel pattern
Avoid gas-forming foodsAvoid gas-forming foods
Increase bulkIncrease bulk
Transient, mild diarrheaTransient, mild diarrhea
attapulgiteattapulgite
bismuth saltsbismuth salts
Establish normal bowel patternEstablish normal bowel pattern
Avoid gas-forming foodsAvoid gas-forming foods
Increase bulkIncrease bulk
Transient, mild diarrheaTransient, mild diarrhea
attapulgiteattapulgite
bismuth saltsbismuth salts
Managementof persistent diarrheaManagementof persistent diarrhea LoperamideLoperamide
Diphenoxylate / atropineDiphenoxylate / atropine
Tincture of opiumTincture of opium
OctreotideOctreotide
LoperamideLoperamide
Diphenoxylate / atropineDiphenoxylate / atropine
Tincture of opiumTincture of opium
OctreotideOctreotide
Anorexia / cachexiaAnorexia / cachexia
Loss of appetiteLoss of appetite
Loss of weightLoss of weight
Loss of appetiteLoss of appetite
Loss of weightLoss of weight
Managementof anorexia / cachexia . . .Managementof anorexia / cachexia . . . Assess, manage comorbid Assess, manage comorbid
conditionsconditions
Educate, supportEducate, support
Favorite foods / nutritional Favorite foods / nutritional supplementssupplements
Assess, manage comorbid Assess, manage comorbid conditionsconditions
Educate, supportEducate, support
Favorite foods / nutritional Favorite foods / nutritional supplementssupplements
. . . Managementof anorexia / cachexia. . . Managementof anorexia / cachexia AlcoholAlcohol
DexamethasoneDexamethasone
Megestrol acetateMegestrol acetate
Tetrahydrocannabinol (THC)Tetrahydrocannabinol (THC)
AndrogensAndrogens
AlcoholAlcohol
DexamethasoneDexamethasone
Megestrol acetateMegestrol acetate
Tetrahydrocannabinol (THC)Tetrahydrocannabinol (THC)
AndrogensAndrogens
Managementof fatigue / weakness . . .Managementof fatigue / weakness . . . Promote energy conservationPromote energy conservation Evaluate medicationsEvaluate medications Optimize fluid, electrolyte intakeOptimize fluid, electrolyte intake Permission to restPermission to rest Clarify role of underlying illness Clarify role of underlying illness Educate, support patient, familyEducate, support patient, family Include other disciplinesInclude other disciplines
Promote energy conservationPromote energy conservation Evaluate medicationsEvaluate medications Optimize fluid, electrolyte intakeOptimize fluid, electrolyte intake Permission to restPermission to rest Clarify role of underlying illness Clarify role of underlying illness Educate, support patient, familyEducate, support patient, family Include other disciplinesInclude other disciplines
. . . Managementof fatigue / weakness. . . Managementof fatigue / weakness Dexamethasone Dexamethasone
feeling of well-being, increased energyfeeling of well-being, increased energy
effect may wane after 4-6 weekseffect may wane after 4-6 weeks
continue until deathcontinue until death
MethylphenidateMethylphenidate
Dexamethasone Dexamethasone
feeling of well-being, increased energyfeeling of well-being, increased energy
effect may wane after 4-6 weekseffect may wane after 4-6 weeks
continue until deathcontinue until death
MethylphenidateMethylphenidate
Fluid balance / edema . . .Fluid balance / edema . . .
Frequently associated with advanced Frequently associated with advanced illnessillness
Hypoalbuminemia Hypoalbuminemia decreased decreased oncotic pressureoncotic pressure
Venous or lymphatic obstruction Venous or lymphatic obstruction may contributemay contribute
Frequently associated with advanced Frequently associated with advanced illnessillness
Hypoalbuminemia Hypoalbuminemia decreased decreased oncotic pressureoncotic pressure
Venous or lymphatic obstruction Venous or lymphatic obstruction may contributemay contribute
. . . Fluid balance / edema. . . Fluid balance / edema
Limit or avoid IV fluidsLimit or avoid IV fluids
Urine output will be lowUrine output will be low
Drink some fluids with saltDrink some fluids with salt
Fragile skinFragile skin
Limit or avoid IV fluidsLimit or avoid IV fluids
Urine output will be lowUrine output will be low
Drink some fluids with saltDrink some fluids with salt
Fragile skinFragile skin
SkinSkin
HygieneHygiene
ProtectionProtection
SupportSupport
HygieneHygiene
ProtectionProtection
SupportSupport
Pressure (decubitus) ulcersPressure (decubitus) ulcers Prolonged pressureProlonged pressure
InactivityInactivity
Closely associated with mortalityClosely associated with mortality
Easier to prevent than treatEasier to prevent than treat
Prolonged pressureProlonged pressure
InactivityInactivity
Closely associated with mortalityClosely associated with mortality
Easier to prevent than treatEasier to prevent than treat
OdorsOdors Topical and / or systemic antibioticsTopical and / or systemic antibiotics
metronidazolemetronidazole
silver sulfadiazinesilver sulfadiazine
Kitty litterKitty litter
Activated charcoalActivated charcoal
VinegarVinegar
Burning candlesBurning candles
Topical and / or systemic antibioticsTopical and / or systemic antibiotics
metronidazolemetronidazole
silver sulfadiazinesilver sulfadiazine
Kitty litterKitty litter
Activated charcoalActivated charcoal
VinegarVinegar
Burning candlesBurning candles
InsomniaInsomnia
Assessment of sleepAssessment of sleep
Other unrelieved symptomsOther unrelieved symptoms
Use family to help assessUse family to help assess
Assessment of sleepAssessment of sleep
Other unrelieved symptomsOther unrelieved symptoms
Use family to help assessUse family to help assess
Management of insomnia . . .Management of insomnia . . . Regular sleep schedule, avoid Regular sleep schedule, avoid
staying in bedstaying in bed Avoid caffeine, assess alcohol intakeAvoid caffeine, assess alcohol intake Cognitive / physical stimulationCognitive / physical stimulation Avoid overstimulationAvoid overstimulation Control pain during the nightControl pain during the night Relaxation, imageryRelaxation, imagery
Regular sleep schedule, avoid Regular sleep schedule, avoid staying in bedstaying in bed
Avoid caffeine, assess alcohol intakeAvoid caffeine, assess alcohol intake Cognitive / physical stimulationCognitive / physical stimulation Avoid overstimulationAvoid overstimulation Control pain during the nightControl pain during the night Relaxation, imageryRelaxation, imagery
. . . Managementof insomnia. . . Managementof insomnia AntihistaminesAntihistamines
BenzodiazepinesBenzodiazepines
NeurolepticsNeuroleptics
Sedating antidepressant (trazodone)Sedating antidepressant (trazodone)
Careful titrationCareful titration
Attention to adverse effectsAttention to adverse effects
AntihistaminesAntihistamines
BenzodiazepinesBenzodiazepines
NeurolepticsNeuroleptics
Sedating antidepressant (trazodone)Sedating antidepressant (trazodone)
Careful titrationCareful titration
Attention to adverse effectsAttention to adverse effects
EEPPEECC
EEPPEECC Common Physical Common Physical
Symptoms Symptoms
SummarySummary
Common Physical Common Physical Symptoms Symptoms
SummarySummary
