ANÁLISIS DESCRIPTIVO

Very few details are available for a modeling attempt, since the subject only made two diagnostic utterances both represented at the symptom level.

UTTERANCE INTERPRETATION 17. on the basis of the spasms it sounds» 1 was thinking there was possibly

increased tone cos that would normally give you spasms in MS and but she’s not relaying any stiffness» I’m having difficulty getting from what she’s said any idea whether the legs are weak she’s not sort o f saying that they feel weak or that they w on’t hold her up»

H yp oth m is 1.1

IF <leg spasms which patient cannot contivl> THEN {could be caused by Increased m uscle tone} BUT patient does not com plain o f leg stiffness / weakness 0)

18. she’s said w obbly and that could go with a proprioceptive loss so it could be»the lack o f use could be a proprioceptive lead thing that she doesn’t know where her feet are and can’t control them because o f that»

Hypodiesis 2.1

IF <legs feel wobbly>THEN {could be caused by proprioceptive deficit} ®

19. I’m not getting any picture o f weakness which 1 suppose»l’m just not getting the right words from the patient that 1 would think describe weakness she’s not saying that her legs collapse underneath her»and I’m not»

Hypothesis 3.1

IF <patienfs symptoms include leg collapse> THEN {could be caused by m uscle weakness} BUT this patient does not appear to be com plaining o f these

symptoms ®

20. with the spasms if they’re that severe»she’s got night spasms and they’re sort o f disrupting her everyday activities kicking her hu sband»l’d expect her tone to be worse but she’s not giving me the picture o f high tone either»so that’s what I’ve got and that’s what my thoughts are so far»so 1 think because I’m getting this rather mixed picture and it’s a little bit unclear to me at the m oment»what symptoms are her main problems

Diagnostic Cues

<night spasms> <kicked husband>

24. so if 1 felt that in a limb then 1 would automatically make assumptions about how difficult it is for this patient to move the limb herself against this resistance but 1 would note»l’d know mentally that she’s got no joint range problems at this point

Hypothesis 4.1

IF <marked resistance to passive movement & movement can be produced> THEN {lack of jo int range Is not a contributory factor} (D

28. §the TA tightness would maybe go with an extensor pattern coming out so again it could possibly give problems with standing and w alking»the feel of the»the feel o f the tightness»do we have 90° at the ankle passive range no OK

Hypothesis 1.2

IF <Tight TA, possible extensor pattem of spasticity>THEN {explains problem s In standing / w alking} (D

34. OK so the information 1 get now is again not exactly conflicting but there is a huge variation in her functional ability so to walk a mile is actually very good with the sort o f limbs that she’s presenting with today and I’m getting the picture that although this is only a week that there were possibly problem s before so w e’ve got som ebody who can walk quite a long way but also falls over quite often at the same time so»this is really frustrating the ability»

Hypothesis 5.1

IF <patientcan walk quite far(1 mile)>

THEN {s u g g e s ts good function} BUT rapid deterioration, falls quite often AND severe symptoms on examination THEN residual problem s from last exacerbation is

limiting functional abilities ®

35. 1 was concerned about the shoes because people who go into slippers a long time do tend to lose there is loss o f range in their soft tissue function and that has long term implications for=ability so we need to find out w hat her lifestyle is and how often a lot of patients do get out of the habit of putting shoes on but it appears that before this week it sounds as if she did actually w ear shoes quite often so that’s quite good

H yp o th esk 5.2

IF <loss of function recently and patient stopped wealing shoes in favour of slippers> THEN {could develop soft tissue tightness which w ill limit function long term } BUT this has been recent

development <D

37. That’s the sort of remark you’d expect from som ebody with proprioceptive loss who gets support from their footw ear

Hypothesis 5.3

IF <better in shoes> THEN fsuooests propriocepdve loss} ®

41. so w e’ve now got symptoms presenting very predom inantly with features on the right side»passive movements

Diagnostic Cue

<(R) side symptoms predominant>

43. OK and I’d be looking here for whether there was a loss o f control a wobble that suggested a loss o f coordination

Hypothesis 1.3

IF <loss of control observed on active movement>THEN {probably diminished

coordination} 0

44. or whether there was a sort of patterning o f the limb which suggested the increase o f tone the abnormal use of tone to produce the m ovement that’s what I’d be visualising

Hypothesis 1.4

IF <limb moves in gross movement pattem>THEN {m ovem ent Is being produced by abnorm al use of muscle

tone} ®

46. OK so w e’re getting the picture of the limb that’s much more normal on the left

Diagnostic Cue

<(L) side more normal>

51. and that gives me information about sort o f delayed neural responses and 1 know from that test that if she that if the inform ation’s taking that long to get to your head in supine then you haven’t got a chance on your feet cos you haven’t got the time lag that’s probably about it

Diagnostic Cue

54. OK so I'm getting a much more definite picture now here of somebody who does have increased tonus=she is in abnormal tone to move so the spasms that we heard about earlier 1 would now think of were a presentation of that and she also has this proprioceptive loss

DiagnosticCues <Spasms> <Abnormal tone> <Proprioceptive lo$s>

62. =on that information it sounds like well when she said she was hip hitching I first thought there was hip weakness then 1 thought no hang on wait a minute we’ve got this increased tone and then she tells me about the foot and it’s because the foot is stopping her moving so I’m fairly sure now that it’s increased tonus that’s giving her the walking difficulties=what I’ve looked at or the way she’s just described her walking pattern to me

Hypothwte 5.4: "

IF hMung & racant f u n e r a l losses> THEN {could be due to muscle weakness} BUT tone is increased and' there Is foot drop THEREFORE gait ^ problems are due to tone (and foot drdp)

64.SO it gets stuck in the straight position OK and so it certainly seems that although she’s got marked proprioceptive loss that her spasm is the predominant problem giving her most of the current things I’m thinking that at this stage

Hypothesis 5.5 ^

l | <gait probtems,foof drop, futKtiona! toss

& incmased tone>THEN {main problem is from spasticity} ALTHOUGH

proprioceptive toss is contributing to the

dysifunctigp ^ 3 )

76. right actually that's interesting cos 1 asked her earlier if she had any help in the house and she actually said no=so I’m just picking up that there are mild inconstancies now in this patient which is again something that you sometimes find in MS or she might not have understood my initial question so 1 don't make a decision on that 1 just file it away really for reference that’s OK=l’m not clear with her answers whether she really has a problem with extreme fatigue as some MS people do=l’m certainly not getting a daily pattem of fatigue just a pattern of fatigue with stress which the particular stresses of life which is I’m not going to deal with it at this particular point in the assessment

DiagnosticCues <inconsistencies in history>

<fatigue>

87. but maybe she just hasn't got good control over it because with all that she’s got quite severe proprioceptive loss

Hypottiesis 5 . 5 ; 0 .FT i .