physical assessment part ii musculoskeletal, mental status, & neurological assessment

Physical Assessment Part IIMusculoskeletal, 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

PHYSICALAppearance Motor Activity

BehaviorEMOTIONAL

Attitude Mood & AffectCOGNITIVE

Orientation Attention & ConcentrationMemory Speech & Language

Thought (Form & Content) PerceptionInsight & 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

AlertnessLevel 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

MemoryImmediate Say a list of single digit numbers & ask patient to

repeat themShort term Have the patient memorize 3 unrelated words &

ask him to repeat them laterLong-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. Accountability3. Excellence4. Duty5. Honor and Integrity6. 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 FunctionI - 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 FunctionIII/IV/VI Oculomotor, Trochlear, Abducens Size, shape of pupils, pupillary response Eye movements 9 cardinal positionsV - 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 FunctionVII - 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 FunctionIX/X - Glossopharyngeal, Vagus Assess quality of speech Assess gag reflexXI - Spinal Accessory Test ability to shrug shoulders & turn the chin from

side to side against resistanceXII - 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 assistancePlease 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