phcl 326 hadeel alkofide april 2011. its evaluated mainly by two methods : 1. inspection 2....

Physical Assessment Part II

Musculoskeletal, Mental Status, & Neurological

Assessment

PHCL 326Hadeel Alkofide

April 2011

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


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


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


Palpation

Limitation in ROM are expressed in

degrees

Palpate joints & surrounding area for

tenderness

Assess for warmth, crepitation, &

deformities


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


Mood

Is the patient’s mood appropriate to situation?

Sad, Angry, Depressed, Anxious

Appropriate/Inappropriate

Mental Status


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


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


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?


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)


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


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


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


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



Reflexes

Cranial Nerve Function

There are 12 cranial nerves

Please refer to table 4-9 page 93 for assistance

Neurological Assessment


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)



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



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



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



Cranial Nerve Function Video



For further assistance

Please visit

http://neuroexam.med.utoronto.ca/


Neurological System

Mental status



Reflexes

They will not be covered here

phcl 326 hadeel alkofide april 2011. its evaluated mainly by two methods : 1. inspection 2....

Documents

palpation slide

palpable crackling sound

movement bradykinesia

time psychomotor agitation

mood descriptors

observable mood

patients mood appropriate

suspicious stability