Clinical Skills: Patient Interview and Physical Examination, Study Guides, Projects, Research of Nursing

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NR Week 3 Study Guide Ch. 1 ● Basic and Advanced Interviewing Techniques Basic Interviewing Techniques ● Active listening: Active listening means closely attending to what the patient is communicating, connecting to the patient's emotional state, and using verbal and nonverbal skills to encourage the patient to expand on his or her feelings and concerns. ● Empathic responses: Empathy has been described as the capacity to identify with the patient and feel the patient's pain as your own, then respond in a supportive manner. ● Guided questioning: Guided questions show your sustained interest in the patient's feelings and deepest disclosures and allows the interviewer to facilitate full communication, in the patient's own words, without interruption. ● Nonverbal communication: Nonverbal communication includes eye contact, facial expression, posture, head position and movement such as shaking or nodding, interpersonal distance, and placement of the arms or legs—crossed, neutral, or open. ● Validation: Validation helps to affirm the legitimacy of the patient's emotional experience. ● Reassurance: Reassurance is an appropriate way to help the patient feel that problems have been fully understood and are being addressed. ● Partnering: When building rapport with patients, express your commitment to an ongoing relationship. ● Summarization: Giving a capsule summary of the patient's story during the course of the interview to communicate that you have been listening carefully. ● Transitions: Inform your patient when you are changing directions during the interview. ● Empowering the patient: Empower patients to ask questions, express their concerns, and probe your recommendations in order to encourage them to adopt your advice, make lifestyle changes, or take medications as prescribed. Advanced Interview Techniques 2 𝖮 Determine scope of assessment: Focused vs. Comprehensive: ■ Comprehensive: Used patients you are seeing for the first time in the office or hospital. Includes all the elements of the health history and complete physical examination. ● Is appropriate for new patients in the office or hospital ● Provides fundamental and personalized knowledge about the patient ● Strengthens the clinician–patient relationship ● Helps identify or rule out physical causes related to patient concerns ● Provides a baseline for future assessments ● Creates a platform for health promotion through education and counseling ● Develops proficiency in the essential skills of physical examination ■ Focused: For patients you know well returning for routine care, or those with specific “urgent care” concerns like sore throat or knee pain. You will adjust the scope of your history and physical examination to the situation at hand, keeping several factors in mind: the magnitude and severity of the patient’s prob- lems; the need for thoroughness; the clinical setting—inpatient or outpatient, primary or subspecialty care; and the time available. ● Is appropriate for established patients, especially during routine or urgent care visits ● Addresses focused concerns or symptoms ● Assesses symptoms restricted to a specific body system ● Applies examination methods relevant to assessing the concern or problem as thoroughly and carefully as possible 𝖮 Being aware of your reactions helps develop your clinical skills. 𝖮 Your success in eliciting the history from different types of patients grows with experience, but take into account your own stressors, such as fatigue, mood, and overwork. 𝖮 Self-care is also important in caring for others. Even if a patient is challenging, always remember the importance of listening to the patient and clarifying his or her concerns. ● Components of the Health History ● Initial information ■ Date and time of history-time is especially important in emergent 5 ■ Documents presence or absence of common symptoms related to each of the major body systems ■ Understanding and using Review of Systems questions may seem challeng- ing at first. These “yes-no” questions should come at the end of the inter- view. Think about asking a series of questions going from “head to toe.” It is helpful to prepare the patient by saying, “The next part of the history may feel like a hundred questions, but it is important to make sure we have not missed anything.” ■ Most Review of Systems questions pertain to symptoms, but on occasion, some clinicians include diseases like pneumonia or tuberculosis. ■ Note that as you elicit the Present Illness, you may also draw on Review of Systems questions related to system(s) relevant to the Chief Complaint to establish “pertinent positives and negatives” that help clarify the diagnosis. ■ For example, after a full description of chest pain, you may ask, “Do you have any history of high blood pressure . . . palpitations . . . shortness of breath . . . swelling in your ankles or feet?” or even move to questions from the Respiratory or Gastrointestinal Review of Systems ■ The Review of Systems questions may uncover problems that the patient has overlooked, particularly in areas unrelated to the Present Illness. Significant health events, such as past surgery, hospitalization for a major prior illness, or a parent’s death, require full exploration. Keep your technique flexible. ■ Remember that major health events discovered during the Review of Systems should be moved to the Present Illness or Past History in your write-up. ■ ■ Some experienced clinicians do the Review of Systems during the physical examination, asking about the ears, for example, as they examine them. If the patient has only a few symptoms, this combination can be efficient. If there are multiple symptoms, however, this can disrupt the flow of both the history and the examination, and necessary note taking becomes awkward 6 7 ● Subjective versus Objective Data ● Subjective versus Objective Data (pg. 7) Subjective Data (symptoms) Objective Data (signs) What the patient tells you What is observed during physical examination Patients history, from Chief Laboratory information, test 10 2. Quality 3. Quantity or severity 4. Timing, including onset, duration, and frequency 5. The setting in which it occurs 6. Factors that have aggravated or relieved the symptom 7. Associated manifestations 𝖮 ● Adaptive Questioning ( pg. 69-71) ● Adaptive questioning also known as guided questioning ● ● Techniques of Guided Questioning ● ●Moving from open-ended to focused questions ● Using questioning that elicits a graded response ● ●Asking a series of questions, one at a time ● ●Offering multiple choices for answers ●Clarifying what the patient means ● ●Encouraging with continuers ● ●Using echoing ● Challenging Patients Challenging Patients: The silent patient. The confusing patient. The patient with impaired capacity. The talkative patient. The angry or disruptive patient. The patient with a language barrier. The patient with low literacy or low health literacy. The hearing impaired patient. The blind patient. The patient with limited intelligence. The patient seeking personal advice. The seductive patient. Ch. 4 ● General Approach to the Physical Examination ● Interview Facilitation 𝖮 Use open-ended questions-helps to encourage the patient to describe what they are experiencing 𝖮 Listen and ask common-sense questions 𝖮 Follow a thorough and systematic sequence to history taking and 11 physical examination 𝖮 Keep an open mind toward both the patient and the clinical data 𝖮 Always include "the worst-case scenario" in your list of possible explanations of the patient's problem, and make sure it can be safely eliminated 𝖮 Analyze any mistakes in data collection or interpretation 𝖮 Confer with colleagues and review the pertinent clinical literature to clarify uncertainties 𝖮 Apply the principles of evaluating clinical evidence to patient information and testing 𝖮 As you talk with and examine the patient, heighten your focus on the patient’s mood, build, and behavior 𝖮 1. Reflect on your approach to the patient: When greeting the patient identify yourself as a student, beginners spend more time in certain areas and that is ok but just warn the patient that you may want to listen to their heart a little longer but that does not mean anything is wrong ■ Avoid interpreting your findings, you are not the patients primary care provider ■ Avoid negative reactions or showing distaste when finding abnormalities 𝖮 2. Adjust the lighting and the environment: set the stage so that both you and the patient are comfortable; good lighting and a quiet environment enhance what you see and hear however may be hard to arrange 𝖮 3. Check your equipment: The following equipment is needed: ■ An ophthalmoscope and an otoscope. If you are examining children, the otoscope could allow pneumatic otoscopy. ■ ●A flashlight or penlight ■ ● Tongue depressors ■ A ruler and a flexible tape measure, preferably marked in centimeters ■ ●Often a thermometer ■ ●A watch with a second hand ■ ●A sphygmomanometer ■ ●A stethoscope with the following characteristics: ■ ●Ear tips that fit snugly and painlessly. To get this fit, choose ear tips of the proper size, align the ear pieces with the angle of your ear canals, and adjust the spring of the connecting metal band to a comfortable tightness. ■ ●Thick-walled tubing as short as feasible to maximize the transmission of sound: ∼30 cm (12 inches), if possible, and no longer than 38 cm (15 inches) ■ ●A bell and a diaphragm with a good changeover mechanism ■ ●A visual acuity card 12 ■ ●A reflex hammer ■ ●Tuning forks, both 128 Hz and 51 ■ Cotton swabs, safety pins, or other disposable objects for testing sensation and two-point discrimination ■ ●Cotton for testing the sense of light touch ■ ●Two test tubes (optional) for testing temperature sensation ■ ●Gloves and lubricant for oral, vaginal, and rectal examinations ■ ● Vaginal specula and equipment for cytologic and bacteriologic studies ■ ●Paper and pen or pencil, or desktop or laptop computer 𝖮 4. Make the patient comfortable. Show sensitivity to privacy and patient modesty; this conveys respect for the patients vulnerability 𝖮 5. Observe standard and universal precautions. 𝖮 6. Choose the sequence, scope, and positioning of examination ■ Four classic techniques for for physical examination: ● Inspection ● Palpitation ● Percussion ● Auscultation 𝖮 ● Vital Signs CCh. 6 ● Integumentary Assessment and Modification for Age ● Normal VS. Abnormal Findings and Interpretation ● Melanoma Clinicians should apply the ABCDE rule. (page 178) ABCDE Rule: Asymmetry: (compare one side to the other) Border irregularity: look for ragged, notched or blurred Color variations: more than 2 colors(blue black) (brown red), loss of pigment, or redness Diameter >6 mm: size of pencil eraser Evolving: changing rapidly in size, symptoms, or morphology (usually asymmetrical) 15 Assessment findings Tinea capitis: Round patchy scales on scalp, occasionally alopecia develops, most common in pediatric patients Tinea corporis: rash, pruritus, well-circumscribed, red, scaly plaque usually on the trunk, may occur in groups of 3 or more Tinea cruris: pruritus, well-marginated half moon plaques in groin and/or upper thighs, may appear as vesicles, may take on eczema appearance from chronic scratching, does not affect the scrotum or penis, rare in pediatric patients before puberty Tinea pedis: itching, malodorous, and burning of feet, laceration in toe webs, scaling or blistering on soles of feet, bacterial super infections possible, spreads easily to groin area and hands Tinea versicolor: well-marginated lesions of varying colors (white, red, brown); hence the name versicolor, rare itching, common in axillary, shoulders, chest, back (sebum rich areas) ● Bilateral erythematous, geographic patches with peripheral scaling, on inner thighs bilaterally, sparing the scrotum; tinea cruris. Fungal infection known as jock itch. Itchy, red, often ring-shaped rash in these warm, moist areas of your body. ● Prevention: good personal hygiene, remove wet clothes as soon as possible, dry between toes after showering and bathing, avoid direct contact with surfaces in public bathing facilities, put socks on before undergarments, avoid sharing clothing, Sports equipment, or towels with other people. ● Pityriasis ● An oval pink or rose colored rash that starts as a large patch. One large patch usually remains the first week followed by several more patches. The patches occur particularly on the back and abdomen. The pattern is similar to a Christmas tree. They usually disappear without treatment. They last 6-8 weeks. The cause is unknown. 16 ● Lyme Disease Ch. 7 ● Lymph Nodes Lymph Nodes Are variably classified. Chapter 7 pg. 259 has a chart of the classification and the direction of how the lymph nodes drain. Nodes are normally round or ovoid, smooth and smaller than the submandibular gland. The gland is larger and has a lobulated, slightly irregular surface. **Note that the tonsillar, submandibular, and submental nodes drain portions of the mount and throat as well as the face. **Lymphatic drainage patterns are helpful for assessing possible malignancy or infection. To look for this, look for enlargement of the neighboring regional lymph nodes; when a node is enlarged or tender, look for source in its nearby drainage area. Techniques for examining lymph nodes: First inspect the neck- is it symmetrical? Do you see any masses or scars? Look for enlargement of the parotid or submandibular glands, and note any visible lymph nodes. **If you see a scar from a past thyroid surgery, this is a clue to an unsuspected thyroid or parathyroid disease. Second, palpate the lymph nodes: 1) Use pads of your index finger and middle fingers, press gently, moving the skin over the underlying tissues in each area. 2) Make sure the patient is relaxed, with the neck flexed slightly forward and if needed, turned slightly toward the side being examined. 3) **You can usually examine both sides at once, noting both the presence of lymph nodes as well as asymmetry. However, for the submental node, it is helpful to feel with one hand while bracing the top of the head with the other hand. 4) Sequence for the following nodes: ⮚ Preauricular- in front of the ear ⮚ Posterior auricular- superficial to the mastoid process (behind the ear). ⮚ Occipital- at the base of the skull posteriorly ⮚ Tonsillar- at the angle of the mandible ⮚ Submandibular- midway between the angle and the tip of the mandible. These 17 nodes are usually smaller and smoother than the lobulated submandibular gland against which they lie. ⮚ Submental- in the midline a few cm’s behind the tip of the mandible. ⮚ Superficial cervical- superficial to the sternocleidomastoid ⮚ Posterior cervical- along the anterior edge of the trapezius ⮚ Deep cervical chain- deep to the sternocleidomastoid and often inaccessible to examination. **Hook your thumb and fingers around either side of the sternocleidomastoid muscle to find them. ⮚ Supraclavicular- deep in the angle formed by the clavicle and the sternocleidomastoid. ⮚ **Enlargement of the supraclavicular node, especially on the left, suggest possible metastasis from a thoracic or an abdominal malignancy. 5) Note the following when assessing lymph nodes: ⮚ Node size ⮚ Shape ⮚ Delimitation (discrete or matted together) ⮚ Mobility ⮚ Consistency ⮚ Tenderness 6) Small, mobile, discrete, nontender nodes, sometimes called “shotty” are frequently found in normal people. 7) Describe enlarged lymph nodes in two dimensions, maximal length and width, for example, 1 cm x 2 cm. Also note any overlying skin changes (erythema, induration, drainage or breakdown). 8) If enlarged or tender nodes, if unexplained call for (1) re-examination of the regions they drain and (2) careful assessment of the lymph nodes in other regions to identify regional from generalized lymphadenopathy. 9) Techniques for preauricular and cervical lymph nodes: ⮚ Using the pads of the second and third fingers palpate the preauricular nodes with a gentle rotary motion. Then examine the posterior auricular and occipital lymph nodes. ⮚ **Tender nodes suggest inflammation; hard or fixed nodes suggest malignancy. ⮚ Palpate the anterior superficial and deep cervical chains, located anterior and superficial to the sternocleidomastoid. Then palpate the posterior cervical chain along the trapezius and along the sternocleidomastoid. ⮚ Flex the patient’s neck slightly forward toward the side being examined. ⮚ Examine the supraclavicular nodes in the angle between the clavicle and the sternocleidomastoid. ⮚ ***If you feel supraclavicular lymph nodes, a through work-up is warranted. 10) Generalized lymphadenopathy is seen in multiple infectious, inflammatory, or malignant conditions such as HIV or AIDS, infectious mononucleosis, lymphoma, leukemia, and sarcoidosis. 11) Occasionally, you mistake a band of muscle or an artery for a lymph node. Unlike a muscle 20 retina than flame-shaped hemorrhages. Diabetes is a common cause. Microaneurysms: Tiny, round, red spots commonly seen in and around the macular area. They are minute dilations of the very small retinal vessels, the vascular connections are too small to be seen with an opthalmoscope. A hallmark of diabetic retinopathy. Hypertensive Retinopathy: marked arteriolar-venous crossing changes are seen, especially along the inferior vessels. Copper wiring of the arterioles is present. A cotton-wool spot is seen just superior to the disc. Incidental disc drusen are also present but are unrelated to the hypertension. Hypertensive Retinopathy with Macular Star: note the punctate exudates are readily visible, some are scattered, others radiate from the fovea to form a macular star. Note the two small, soft exudates about 1 disc diameter from the disc. Find the flame-shaped hemorrhages sweeping toward 7,8, 10 o’clock, These two fundi show changes typical of severe hypertension retinopathy, which is often accomplished by the papliledema. (see page 283 for picture to better understand). Diabetic Retinopathy: (see page 284 for pictures) Ch. 8 ● Lung/Thorax Assessment and Modification for Age ● Normal VS. Abnormal Findings and Interpretation ● Lung Sounds -Auscultation is the most important examination technique for assessing air flow through the tracheobronchial tree. Auscultation involves (1) listening to the sounds generated by breathing, (2) listening for any adventitious (added) sounds, and (3) if abnormalities are suspected, listening to the sounds of the patient’s spoken or whispered voice as they are transmitted through the chest wall. Before beginning auscultation, ask the patient to cough once or twice to clear mild atelectasis or airway mucus that can produce unimportant extra sounds. -Listen to the breath sounds with the diaphragm of your stethoscope after instructing the patient to breathe deeply through an open mouth. Always place the stethoscope directly on the skin. Clothing alters the characteristics of the breath sounds and can introduce friction and added sound 21 -Normal breathing is quiet and easy—barely audible near the open mouth as a faint whish. When a healthy person lies supine, the breathing movements of the thorax are relatively slight. -Audible high-pitched inspiratory whistling, or stridor, is an ominous sign of upper airway obstruction in the larynx or trachea that requires urgent airway evaluation. Wheezing is either expiratory or continuous. Learn to identify breath sounds by their intensity, their pitch, and the relative duration of their inspiratory and expiratory phases. Normal breath sounds are: o Vesicular, or soft and low pitched. They are heard throughout inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration. o Bronchovesicular, with inspiratory and expiratory sounds about equal in length, at times separated by a silent interval. Detecting differences in pitch and intensity is often easier during expiration. o Bronchial, or louder, harsher and higher in pitch, with a short silence be- tween inspiratory and expiratory sounds. Expiratory sounds last longer than inspiratory sounds. o Tracheal, or loud harsh sounds heard over the trachea in the neck Listen for any added, or adventitious, sounds that are superimposed on the usual breath sounds. Detection of adventitious sounds—crackles (sometimes called rales), wheezes, and rhonchi—is an important focus of your examination, often leading to diagnosis of cardiac and pulmonary conditions. o Crackles can arise from abnormalities of the lung parenchyma (pneumonia, interstitial lung disease, pulmonary fibrosis, atelectasis, heart failure) or of the airways (bronchitis, bronchiectasis) o Wheezes arise in the narrowed airways of asthma, COPD, and bronchitis. o Many clinicians use the term “rhonchi” to describe sounds from secretions in large airways that may change with coughing. 1. In some normal people, crackles may be heard at the anterior lung bases after maximal expiration. Crackles in dependent portions of the lungs may also occur after prolonged recumbency. 2. If you hear wheezes or rhonchi, note their timing and location. Do they change with deep breathing or coughing? Beware of the silent chest, in which air movement is minimal. In the advanced airway obstruction of severe asthma, wheezes and breath sounds may be absent due to low respiratory airflow (the “silent chest”), a clinical emergency. 3. Note that tracheal sounds originating in the neck such as stridor and vocal cord dysfunction can be transmitted to the chest and mistaken for wheezing, leading to inappropriate or delayed treatment. 4. Note any pleural rubs, which are coarse, grating biphasic sounds heard primarily during expiration. 22 ● Pneumonia Acute illness: timing varies with causative agent Associated Symptoms: Pleuritic pain, cough, sputum, fever, though not necessarily present Mycoplasma and Viral Pneumonias Cough and Sputum: Dry and hacking often with mucoid sputum Associated Symptoms and Setting: Acute febrile illness, often with malaise, headache, and possibly dyspnea Bacterial Pneumonias Cough and Sputum: Sputum is mucoid or purulent; may be blood-streaked, diffusely pinkish, or rusty Associated Symptoms and Setting: Acute illness with chills, often high fever, dyspnea, and chest pain. Commonly from Streptococcus pneumonia, Haemophilus influenza, Moraxella catarrhalis; Klebsiella in alcoholism (Chapter 8 The Thorax and Lungs) ● Asthma Ch. 16 Musculoskeletal Assessment and Modification for Age Normal VS. Abnormal Findings and Interpretation Back pain Low Back Pain. The estimated lifetime prevalence of low back pain in the United States population is over 80%. Spinal disorders are among the most frequent reasons for adult outpatient visits, and the annual U.S. economic costs attributed to diagnosing and managing low back pain and lost productivity exceed $100 billion. Most patients with acute low back pain get better within 6 weeks; for patients with nonspecific symptoms, clinical guidelines emphasize reassurance, staying active, analgesics, muscle relaxants, and spinal manipulation therapy.Overall, about 10% to 15% of patients with acute low 25 of risk of disease, involves proinflammatory cytokines Progression and Duration: often chronic (in >50%) with remissions and exacerbations Swelling: frequent swelling of synovial tissue in joints or tendon sheaths: also subcutaneous nodules Redness, warmth, and tenderness: tender, often warm, but seldom red. Stiffness: prominent, often for an hour or more in the mornings, also after inactivity Limitation of Motion: often develops, affected by associated joint contractures and subluxation, bursitis, and tendinopathy Generalized symptoms: weakness, fatigue, weight loss, and low fever are common. Assess for joint pain: Articular or Extra-articular* joint pain may be polyarticular, involving several joints, typically four or more. If polyarticular, what is the pattern of involvement.. Migrating from joint to joint or steadily spreading from one joint to multiple joints?.Is the involvement symmetric, affecting similar joints on both sides of the body? ***In RA, the pattern is additive and progressive with symmetric involvement. Inflammatory arthritides are more common in women. Inflammatory or non-inflammatory: Try to determine whether the joint pain is inflammatory or noninflammatory. Different mechanisms appear to be involved- interleukins and tumor necrosis factor in inflammatory joint pain, and prostaglandins, chemokines, and growth factors on noninflammatory pain ***Inflammatory disorders have many causes: immune-related for RA Localized or diffuse. Ask the patient which joints are painful. Joint pain can be monoarticular, oligoarticular involving two to four joints, or polyarticular. If there is pain in more than one joint, si the pattern of involvement symmetric or asymmetric*** Polyarthritis may be viral or inflammatory from RA Inspection: look for symmetry involvement: *** RA is typically polyarticular and symmetrical 26 Inspection and Palpation: assess the surrounding tissues, noting skin changes, subcutaneous nodules, and muscle atrophy. ***Look for subcutaneous nodules in RA Rheumatoid nodules: in chronic RA, look for small lumps on the helix or antihelix and additional nodules elsewhere on the hands and along the surface of the ulna distal to the elbow (p.702), and on the knees and heels. Ulceration may result from repeated injuries. These nodules may antedate the arthritis Test range of motion and maneuvers to demonstrate limitations in ROM or joint instability from excess mobility of joint ligaments called ligamentous laxity***decreased ROM is present in arthritis with tissue inflammation or surrounding fibrosis or bony fixation (ankylosis) Anterior cruciate ligament (ACL) laxity occurs in knee trauma: muscle atrophy and weakness seen in RA Joint pain: associated constitutional symptoms and systemic manifestation symptoms such as fever, chills, rash, fatigue, anorexia, weight loss, and weakness.***constitutional symptoms are common in RA, SLE, PMR and other inflammatory arthritides. High fever and chills suggest an infectious cause. Assessing the four signs of inflammation 1.) Swelling 2.) Warmth 3.) Redness: redness overlying skin is the least common sign of inflammation near the joints and is usually seen in more superficial joints like fingers, toes, and knees. ***redness over a tender joint suggests septic or crystalline arthritis, or possibly RA 4.) Pain or tenderness Palpate the metatarsophalangeal (MTP) joints for tenderness. Compress the forefoot between the thumb and fingers. Exert pressure just proximal to the heads of the first and fifth metatarsals. ***Tenderness on compression is an early sign of RA. Acute RA : tender, painful, stiff joints in RA, usually with symmetric involvement on both sides of the body. The distal interphalangeal (DIP), metacarpophalangeal (MCP), and wrist joints are the most frequently affected. Note the fusiform or spindle-shaped swelling of the PIP joints in acute disease. 27 Chronic RA: In chronic disease, note the swelling and thickening of the MCP and PIP joints. ROM becomes limited, and fingers amy deviate toward the ulnar side. The interosseous muscles atrophy. The fingers may show “swan neck” deformities (hyperextension of the PIP joints with fixed flexion of the distal interphalangeal (DIP) joints. Less common is a boutonniere deformity (persistent flexion of the PIP joint with hyperextension of the DIP joint). Rheumatoid nodules are seen in the acute or the chronic stage. Subcutaneous nodules may develop at pressure points along the extensor surface of the ulna in patients with RA or acute Rheumatic fever. They are firm and nontender. They are not attached to the overlying skin but may be attached to the underlying periosteum. They can develop in the area of the olecranon bursa, but often occur more distally. CCh. 17 Neurological Assessment and Modification for Age The neurological exam can be organized into 6 or 7 categories: (1) mental status: used to establish the reliability of the rest of the neuro exam. Most of the mental status assessment can be completed via observation and through their answers to your questions during history taking. (making eye contact, does not drift or need things repeated, able to converse normally, and answers questions about medical history and recent eventing in a consistent manner) 7 areas of mental status need to be considered: 1. Level of awareness. 2. Attentiveness: Is the patient paying attention to you and your questions or is he distractible and requiring re-focusing? 3. Orientation: to self, place, time. Disorientation to time typically occurs before disorientation to place or person. Disorientation to self is typically a sign of psychiatric disease. 4. Speech & language: includes fluency, repetition, comprehension, reading, writing, 30 muscles (e.g., clench teeth). Note, however, that symmetrically brisk, diminished, or even absent reflexes may be found in normal people. The muscle stretch reflexes that are the most clinically relevant and that you should know how to obtain include the biceps, triceps, knee, and ankle. The superficial (cutaneous) reflexes are elicited by applying a scratching stimulus to the skin. The only superficial reflex that you need to know other than the corneal is the plantar reflex. An abnormal plantar reflex (extension of the great toe with fanning out of the other toes upon stimulation of the plantar surface of the foot) is a specific indicator of corticospinal tract dysfunction and may be the only sign of ongoing disease or the only residual sign of previous disease. (5) Sensory system: The sensory exam can be frustrating at times because of its subjective nature and reliance on cooperation. It is prudent to test sensation early in your exam if you anticipate poor cooperation to be a factor. Explain to your patients what you are going to do and what you expect of them, then have them close their eyes for the testing. Be aware of the fact that patients may report differences in sensation in the presence of normal sensory function because of actual differences in the stimulus intensity applied— you are not a machine and cannot apply identical pressure each time you poke with a pin. Both superficial and deep sensation should be tested in all four limbs. Always compare side-toside, asking, “Are these about the same?” rather than leading questions like, “Is this sharp?” or “Which is stronger?” Remember that thresholds for detecting a stimulus are very low in distal or hair covered areas and higher over thick skin. Superficial sensation (pain and temperature) is mediated by unmyelinated and small myelinated nerve fibers via the spinothalamic tract. Pain sensation can be tested with a safety pin or the broken end of a cotton swab; temperature sensation can be tested with a cool metal object (like a tuning fork). In the patient complaining of sensory symptoms, demonstrate what the pin/temperature should feel like in an uninvolved area. Since the boundary between “dull” and “sharp” or “warm” and “cool” is usually more readily perceived by the patient if you move your stimulus from the abnormal area to the normal area rather than vice versa, asking the patient to report when the stimulus begins to feel stronger is the best way to identify the margins of a hypesthetic area. Sometimes it is useful to apply the stimulus to an uninvolved part of the body and say, “If this sharpness/coolness is worth $1, how much is this worth?” and then apply the pin/cool object elsewhere. Deep sensation (pressure, position sense, and vibration) is mediated by large fibers via the dorsal and lateral columns. Vibration and position sense (proprioception) should be tested at the most distal joint of the limb. If sensation at this joint is impaired, increase 31 the intensity of the stimulus and/or move proximally. Emphasis should be on the toes and feet, where the longest, large myelinated fibers are most likely to be impaired. The appropriate tuning fork to use in testing vibration is 128-Hz. You should know your own tuning fork perception and the usual time it takes to fade away. But there are no absolutes for how long a normal person should be able to feel a vibratory stimulus at a particular joint because this is dependent on how hard you strike a tuning fork, the patient’s age, etc. It is most important to compare side-to-side perception. For position sense testing, stabilize the joint with one hand and avoid a push-pull stimulus that lets the patient cheat. For example, in the great toe, steady the interphalangeal joint with one hand and hold the sides of the distal phalanx with the other to move it up and down. Make sure the patient understands the only choices are up or down—there is no sideways or middle. Normal thresholds should be no more than 2 or 3 degrees. There is a third category of sensation, integrative sensation, which requires higher level processing of the above primary sensory modalities and includes such functions as stereognosis (ability to recognize objects by touch), graphesthesia (ability to recognize letters or numbers drawn on the finger or palm), 2-point discrimination (ability to detect two sharp stimuli that are presented simultaneously at decreasing distance on the skin), double simultaneous stimulation (ability to detect two stimuli applied simultaneously to opposite sides of the body), and constructional ability (copying simple and complex forms, drawing a clock). You will learn more about integrative sensation next year and in your third year clerkship. The Romberg test is another maneuver that is used to detect impaired sensory input. The patient is first asked to stand with the feet together and eyes open and then to close the eyes. An abnormal response (“positive Romberg sign”) is for the patient to be able to stand upright when the eyes are open, but to sway/fall when the eyes are closed. Contrary to popular belief, a positive Romberg sign is not an indication of cerebellar disease—the patient with cerebellar or other motor dysfunction will have a hard time maintaining an upright posture with the feet together regardless of whether the eyes are open or closed. Rather, it is an indication of either impaired proprioception or vestibular dysfunction. There are three sensory inputs to maintain truncal stability—vision, proprioception, and vestibular function. Patients with impairment of one of these systems are usually able to compensate and maintain truncal stability. They cannot usually compensate when a second system (vision, when the eyes are closed) is removed. For the screening sensory exam, you should perform one test of superficial sensation (pain or temperature) and one of deep sensations (proprioception is more useful than vibration since distal vibratory sense is lost in otherwise healthy elderly patients) in each limb. Since the majority of asymptomatic sensory deficits you 32 will pick up are neuropathies and the majority of these begin distally, testing at the most distal aspect of the limb is usually sufficient. (6) Coordination and gait Test coordination at rest and with action, in the trunk (e.g., ability to maintain an erect posture), and in the limbs. Impairment of coordination may be detected through simple observation of the patient performing routine acts such as signing his name, reaching for objects, or getting onto the examination table. Specific tests to look for impaired coordination in the limbs include finger-to-nose (patient alternately touches your outstretched finger and his nose), heel-knee-shin (patient runs the heel of one foot down the shin of the other), rapid alternating movements (patient alternately taps the dorsal and plantar surface of one hand onto the other hand), and finger or toe tapping. In all cases, you should be looking at rhythm, steadiness, speed, and precision of movements. Loss of the ability to judge and control distance, speed, and power of a motor act is termed dysmetria. Since walking requires proper functioning of the cerebellum and motor, sensory, and vestibular systems as well as a whole host of reflexes, assessment of gait can provide important information to guide the focus of the rest of the neurological exam. It is for this reason that many physicians like to watch the patient walk at the very beginning of the exam. The specific aspects of gait for you to pay attention to include body and extremity posture; length, speed, and rhythm of steps; base of gait (how far apart are the legs); arm swing; steadiness; and turning. Testing tandem gait (walking heel to toe) can be helpful, though many otherwise normal elderly patients cannot perform the task. The screening exam must include an assessment of gait. Approach the exam systematically and establish a routine so as not to leave anything out. During the course of the exam it is important to look for the distribution of abnormalities (e.g., proximal vs. distal, arms vs. legs, left vs. right). For sensory testing in particular, it is important to let patients know what you are going to do and what you expect of them. Perform a screening neuro exam in all patients, even those w/o neuro complaints, that is sufficient for detection of significant neurologic disease. 35 True syncope is defined as a sudden but temporary loss of consciousness and postural tone from transient global hypoperfusion of the brain. Nurse practitioners need to obtain a complete description of the event. What was the patient doing when the event occurred, was the patient standing, sitting, or lying down. Were there any triggers or warning symptoms? How long the episode lasted and could voices still be heard? It is important to obtain how fast or slow the onset and offset of the episode was. Did the patient have any palpitations present for the episode? Is there a history of heart disease or seizure disorders. If onset was abrupt and without warning seizure should be considered. Interview witnesses that were present if possible. Vasovagal syncope is the most common cause of syncope and includes early symptoms of nausea, diaphoresis, and pallor triggered by a fearful or unpleasant event, medicated hypotension, with a slow onset and offset. Other reasons for syncope include orthostatic hypotension, arrhythmias such a VT, and bradyarrhythmias. If both hemispheres are affected, stroke or subarachnoid hemorrhage can cause syncope. See table 17-3 for detailed description reasons/disorders of syncope, mechanism, factors and recovery. Types include: Vasovagal/Vasodepressor Orthostatic hypotension Cough Syncope Micturition Syncope Arrhythmias Aortic Stenosis and Hypertrophic Cardiomyopathy Syncope Hypocapnia due to hyperventilation Hypoglycemia Conversion Disorder with fainting Seizures were reclassified in 2010 as focal or generalized. Focal seizures- are conceptualized as originating within networks limited to one hemisphere. They are discretely localized or more widely distributed. They originate in subcortical structures. Focal seizures do not fall into any recognized set of natural 36 causes. Ictal onset is consistent from one seizure to another. In some cases, more than one seizure type is seen, but each individual seizure type has a consistent site of onset. Focal seizures without impairment of consciousness include : Jacksonian- Tonic than clonic movements that start unilaterally in hand, foot, or face and spread to other body parts on the same side. Other Motor- Turning of the head and eyes to one side, or tonic and clonic movement of an arm or leg without the jacksonian spread. Autonomic symptoms- a funny feeling in the epigastrium, nausea, pallor, flushing, lightheadedness. With subjective sensory or psychic phenomena- numbness, tingling, auditory, hallucinations, olfactory symptoms. Focal seizures with impairment of consciousness- may or may not start with the autonomic and psychic symptoms described above, consciousness is impaired amd motor behaviors such as lip smacking, unbuttoning clothes and chewing are seen. Patient usually becomes amnesic to seizure afterwards, and has a headache. Generalized seizures- are conceptualized as originating at some point within, and rapidly engaging bilaterally distributed networks that include cortical and subcortical structures, but do not necessarily include the entire cortex. In generalized seizures the location and lateralization are not consistent from one seizure to another. They can be asymmetric. They usually begin with body movements, impaired consciousness, or both. If onset of tonic-clonic seizures begins after age 30 years, suspect a partial seizure that has become generalized or a generalized seizure caused by a toxic or metabolic disorder. Types of Generalized Seizures include: Tonic-clonic seizure-patient loses consciousness suddenly, sometimes with a cry, body stiffens into tonic extensor rigidity. Breathing stops, and patient becomes cyanotic. A clonic phase of rhythmic muscular contraction follows. Breathing resumes and is often noisy with excessive salivation. Injury, tongue biting, and urinary incontinence may occur. Absence seizure- A sudden brief lapse of consciousness, with momentary blinking, staring, or movements of the lips and hands but no falling. 2 types are seen: Typical: 37 lasts <10 secs and stops abruptly, Atypical: lasts >10 secs. Myoclonic seizures- sudden, brief, rapid jerks, involving the trunk or limbs. Associated with a variety of disorders. Myoclonic Atonic-Sudden loss of consciousness with falling but no movements. Injury can occur. Pseudoseizures- mimics seizures but are due to conversion disorders. Do not usually follow a neuroanatomic pattern. ● Cranial Nerves 𝖮 12 cranial nerves ■ I-Olfactory-sense of smell ● To test: present familiar smell that is non irritating with eyes open and compressing each nare then have them close their eyes and test each nostril, by compressing each nare with different smells than the familiar 𝖮 Loss of smell can occur in sinus conditions, head trauma, smoking, normal aging, Parkinson’s disease, and cocaine use ■ II-Optic-Vision ● To test visual acuity : have the patient stand 20 feet from Snellen eye chart, if they wear glasses for other than reading they should be wearing them, cover one eye with a card and not fingers to prevent being able to see through the fingers and have them read the smallest line they can- the vision is placed in a 2 number series such as 20/50, the first number indicates the distance of the patient from the chart and the second number is the distance at which a normal eye can see the same line ● To test pupils: will test reaction to light-dilation and constriction using a pen light ● Look into the pupil to look at the fundi for changes in arteries, papilledema, pallor, cup enlargement ■ III-Oculomotor-pupil constriction, opening the eyelid (elevation), most extraocular movements ■ IV-Trochlear-downward and internal rotation of the eye 40 ● Blood clots Increase in cerebrospinal fluid ● Increased production of CSF ● Choroid plexus tumor Decreased re-absorption of CSF ● Obstructive hydrocephalus ● Meningeal inflammation or granulomas Increase in blood volume ● Increased cerebral blood flow during hypercarbia, aneurysms ● Venous stasis from ● Venous sinus thromboses, ● Elevated central venous pressures, e.g., heart failure Other causes ● Idiopathic or benign intracranial hypertension ● Skull deformities such as craniosynostosis ● Hypervitaminosis A, tetracycline use Signs and symptoms: -headaches, vomiting, and altered mental status varying from drowsiness to coma. -visual changes can range from blurred vision, double vision from cranial nerve defects, photophobia to optic disc edema and eventually optic atrophy. -infants in whom the anterior fontanelle is still open may have a bulge overlying the area. Cushing triad is a clinical syndrome consisting of hypertension, bradycardia and irregular respiration and is a sign of impending brain herniation. 41 Evaluation of increased ICP should include: -a detailed history taking -physical examination -funduscopic exam can reveal papilledema which is a tell-tale sign of raised ICP as the cerebrospinal fluid is in continuity with the fluid around the optic nerve. - computed tomography (CT) of the head or magnetic resonance imaging (MRI) can reveal signs of raised ICP such as enlarged ventricles, herniation, or mass effect from causes such as tumors, abscesses, and hematomas, among others. Infants: -Bulging fontanelle is concerning for increased intracranial pressure