phcl 326 hadeel alkofide april 2011. its evaluated mainly by two methods : 1. inspection 2....
TRANSCRIPT
Physical Assessment Part II
Musculoskeletal, Mental Status, & Neurological
Assessment
PHCL 326Hadeel Alkofide
April 2011
Musculoskeletal System
Musculoskeletal System
Its evaluated mainly by two methods :
1. Inspection
2. Palpation
Inspection
Purpose: Assess function for ability to
perform ADL’s
Inspect for symmetry, proportion, &
muscular development
Observe gait, & ability to stand, sit, rise
from sitting position, & grasp objects
Musculoskeletal System
ADLs: Activities of Daily
Living
Routine activities such as
getting dressed, cleaning the
teeth, combing or brushing the
hair, bathing & feeding oneself
Gait:
The way a person walks
Inspection
Inspect joints for symmetry, swelling,
tenderness, & crepitation
Test muscle strength upper & lower
extremities utilizing opposing force
Musculoskeletal System
Crepitation:
Audible or palpable crackling
sound
Palpation
Palpate large & small joints
Assess range of motion (ROM)
Decreased ROM: Arthritis, fibrosis, tissue
inflammation, & fixed joints
Increased ROM: Increased joint mobility &
joint instability
Musculoskeletal System
Palpation
Limitation in ROM are expressed in
degrees
Palpate joints & surrounding area for
tenderness
Assess for warmth, crepitation, &
deformities
Musculoskeletal System
Neurological System
Neurological System
Mental status
Cranial nerve function
Sensory & motor function
Reflexes
Mental Status
PHYSICAL
Appearance Motor Activity
Behavior
EMOTIONAL
Attitude Mood & Affect
COGNITIVE
Orientation Attention & Concentration
Memory Speech & Language
Thought (Form & Content) Perception
Insight & Judgment Intelligence & Abstraction
Mental Status
Physical: 1. Appearance
A summary of the physical presentation
Dress, facial expression
Posture, eye contact
Hygiene & Grooming
“Disheveled”- ruffled appearance
“Unkempt”- poor attention to grooming
Body habits, nourishment status
General description of body type/ build, & nutritional status
Mental Status
Physical: 2. Motor Activity
Quality & the types of actions observed
Reduction in the level of movement (psychomotor retardation)
Slowed movement (bradykinesia)
Decreased movement (hypokinesia)
Absence of movement (akinesia)
Increases in the overall level of movement (psychomotor agitation)
Tremor
Mental Status
Physical: 3. Behavior
Range & Frequency of Spontaneous Movements
Psychomotor activity
Abnormal movements
Psychomotor refers to movements that appear driven from within, by one’s internal emotions at the time
Psychomotor Agitation, vs.
Psychomotor Retardation
Mental Status
Physical: 3. Behavior
Abnormal Movements
Automatisms- “automatic” involuntary movements; form of seizure
Ex. Lip-smacking, eye-blinking, staring
Mannerisms: goal-directed, complex behaviors carried out in an odd way or inappropriate context
Mental Status
Emotional: 1. Attitude
Patients may be:
Open, friendly, cooperative, willing, & responsive
Closed, guarded, hostile, suspicious & passive
Describe responses to questions, expression, posture, eye contact, tone of voice
Mental Status
Emotional: 2. Mood & Affect
Affect: an external expression of an emotional state is potentially observable
Mood: an internal emotional experience that influences perception of the world & behavioral responses
Mental Status
Emotional: 2. Mood & Affect
Mood
Is the patient’s mood appropriate to situation?
Sad, Angry, Depressed, Anxious
Appropriate/Inappropriate
Mental Status
Emotional: 2. Mood & Affect
Mood
Descriptors: euphoric, dysphoric, hostile, fearful, anxious, or suspicious
Stability of mood can also be noted, with the alternation between extreme emotional states being referred to as emotional lability
Mental Status
Emotional: 2. Mood & Affect
Affect
Range, intensity, & variability of affect can be variously portrayed:
Restricted (i.e., low intensity or range of emotional expression)
Flat (i.e., absence of emotional expression)
Exaggerated (i.e., an overly strong emotional reaction)
Mental Status
Cognitive
Alertness Attention & Cooperation Orientation Speech & Vocabulary Memory Insight & Judgment Abstract Thinking Calculation Object Recognition Praxis
Mental Status
Alertness
Level of Consciousness – LOC Alert: Awake, answers questions Lethargic: Sleeps when undisturbed, arouses to
normal voice, answers questions appropriately –may be “fuzzy”
Obtunded: Sleeps most of time. Loud shout or vigorous shake to arouse. Mumbles
Stupor/Semi-coma: Responds only to pain stimuli. Mumbles, moves restlessly. Withdraws to avoid pain/noxious stimuli
Coma: Un-responsive to any stimulus
Mental Status.. Cognitive
Attention & Cooperation
Test attention by seeing if the patient can remain focused on a simple task, such as spelling a short word forward & backward (W-O-R-L-D / D-L-R-O-W is a standard)
These tests of attention depend on language, memory, & some logic functions as well
Degree of cooperation should be noted, especially if it is abnormal, since this will influence many aspects of the exam
Mental Status.. Cognitive
Orientation
Person, place, date/time, event
Time is the first to go, person the last.
Normal: Expressed as oriented x3
Disoriented? All parameters or 1 or 2?
Does the patient re-orient?
Is this a change from baseline?
Mental Status.. Cognitive
Speech & Vocabulary
Have the patient repeat a specific phrase
Note his speech during the whole exam process
Clear, Slurred
Minimal (mostly "yes" and "no" answers, little volunteered information)
Talkative
Rapid/Pressured (as in possible hypomania or mania)
Mental Status.. Cognitive
Memory
Immediate
Say a list of single digit numbers & ask patient to repeat them
Short term
Have the patient memorize 3 unrelated words & ask him to repeat them later
Long-term memory
Ask the patient about a known historical event that happened in his life time
Mental Status.. Cognitive
Insight & Judgment
Insight: a dimension that describes the extent to which patients are aware that they have a problem
Refers to an awareness of the nature & extent of the problem, the effects of their problem on others, & how it is a departure from normal
A strong lack of insight can be an important indicator of unwillingness to accept treatment
Mental Status.. Cognitive
Insight & Judgment
Judgment: The ability to make sound decisions can be compromised for a number of reasons
Ascertain if poor decisions are the result of problems in the cognitive processes involved in the decision making process, motivational issues, or failures to execute a planned course of action
Mental Status.. Cognitive
Professionalism
Six Tenets of Professionalism:
1. Altruism
2. Accountability
3. Excellence
4. Duty
5. Honor and Integrity
6. Respect for Others
Accountability is the
acknowledgment and
assumption of responsibility
for actions, products,
decisions, and policies
Neurological System
Mental status
Cranial nerve function
Sensory & motor function
Reflexes
Cranial Nerve Function
There are 12 cranial nerves
Please refer to table 4-9 page 93 for assistance
Neurological Assessment
Cranial Nerve Function
I - OLFACTORY
Don’t assess unless patient complains of loss of sense of smell or patient has a head injury
Don’t use a noxious stimulus
Ask him to close eyes & identify familiar odor one nostril at a time (Coffee, lemon)
II - OPTIC
Visual acuity
Visual fields
Fundoscopic exam ( eye exam)
Neurological Assessment
Cranial Nerve Function
III/IV/VI Oculomotor, Trochlear, Abducens
Size, shape of pupils, pupillary response
Eye movements
9 cardinal positions
V - Trigeminal
Motor - jaw strength: ask patient to clench teeth
Sense – ability to sense sharp, dull, hot cold, over front half of the face
Neurological Assessment
Cranial Nerve Function
VII - Facial
Observe for facial asymmetry
Observe facial movements when the patient frowns, smiles, whistle, puffs out the cheeks & raises eyebrows
Test patient's ability to identify sweet, sour & salty tastes
VIII – Acoustic
Test hearing
Neurological Assessment
Cranial Nerve Function
IX/X - Glossopharyngeal, Vagus
Assess quality of speech
Assess gag reflex
XI - Spinal Accessory
Test ability to shrug shoulders & turn the chin from side to side against resistance
XII - Hypoglossal
Tongue strength (Stick out tongue)
Note abnormalities, asymmetry, deviation or atrophy
Neurological Assessment
Cranial Nerve Function
Cranial Nerve Function Video
Neurological Assessment
Cranial Nerve Function
For further assistance
Please visit
http://neuroexam.med.utoronto.ca/
Neurological Assessment
Neurological System
Mental status
Cranial nerve function
Sensory & motor function
Reflexes
They will not be covered here