NURS 612 Study guide Key Points to Review for Exam 3

Key Point to Review - Abdomen STUDENT NOTES What are • Onset and duration: when it began; sudden or gradual; persistent, recurrent, intermittent • Character: dull, sharp, burning, gnawing, stabbing, cramping, aching, colicky • Location: of onset, change in location over time, radiating to another area, superficial or deep • Associated symptoms: vomiting, diarrhea, constipation, passage of flatus, belching, jaundice, change in abdominal girth, weight loss or weight gain • Relationship to: menstrual cycle, abnormal menses, intercourse, urination, defecation, inspiration, change in body position, food or alcohol intake, stress, time of day, trauma • Recent stool characteristics: color, consistency, odor, frequency • Urinary characteristics: frequency, color, volume congruent with fluid intake, force of stream, ease of starting stream, ability to empty bladder • Medications: high doses of aspirin, steroids, nonsteroidal anti-inflammatory drugs (NSAIDs) examples of appropriate history of present illness (HPI) questions you may ask a patient with a chief complaint of an abdominal issue? Describe how you would inspect the abdomen. Proper steps to examine abdomen: inspection, auscultation, percussion, and palpation Using tangential lighting, inspect the abdomen for 4 surface characteristics 1. Observe the skin color. It may vary greatly but should have no jaundice, cyanosis, redness, bruises, or discoloration 2. Check for nodules and other lesions, which should not be present 3. Note any scars and draw their location, configuration, and relative size on an illustration of the abdomen 4. Assess the venous return. Above the umbilicus, venous return should be toward the head. Below the umbilicus, it should be toward the feet Inspect the abdominal contour and symmetry • The contour is the abdominal profile from the rib margin to the pubis. It normally may be flat, rounded, or scaphoid. The umbilicus should be centrally located and may be inverted or may protrude slightly. • Contralateral areas of the abdomen should be symmetrical in appearance and contour and should have no distention of bulges • To elicit hidden masses or bulges, have the patient take a deep breath and hold it. The abdomen should remain smooth and symmetrical. Next, have the supine patient raise their head from the table as you inspect the abdomen. Note any masses, hernia, or muscle separation. With the patient’s head at rest, observe for 3 types of abdominal movement 1. Inspect for smooth, even movement with respiration 2. Assess for surface motion from peristalsis. In a thin patient, it normally may be visible. Otherwise, it may signal an intestinal obstruction 3. Note any aortic pulsation in the upper midline. Although pulsation may be visible Key Point to Review - Abdomen STUDENT NOTES in a thin patient, marked pulsation suggest a disorder. Abnormal: • Jaundice or cyanosis • Ascites: a glistening, taut appearance • Redness may indicate inflammation • Cullen sign: bluish periumbilical discoloration that may indicate intraabdominal bleeding • Striae: result of weight gain or pregnancy • GI diseases often produce skin changes: inspect for lesions or nodules • Sister Mary Josephs’ nodule: a pearl-like, enlarged and sometimes painful umbilicus nodule can indicate abdominal malignancy • Distension from umbilicus to pubic area may indicate ovarian tumor, pregnancy, uterine fibroids, or distended bladder • Distension of upper half above umbilicus may indicate tumor pancreatic cyst, or gastric dilation • Asymmetric distension or protrusion may indicate hernia, tumor, cysts • Incisional hernia: caused by defect in abdomen musculature that develops after surgical incision • Umbilical hernia: protrusion of naval • Rippling movement across abdomen may indicate intestinal obstruction • Abdomen aortic pulsation may indicate aneurysm Why do you auscultate the abdomen before you percuss or palpate? Auscultate before you percuss or palpate because these techniques can alter bowel sounds. Listen for bowel sounds and note their frequency and character. Describe how and where you auscultate the abdomen. What are the three additional sounds you assess? What is normal Using the diaphragm of a warmed stethoscope, listen for bowel sounds and note their frequency and character Expect to hear clicks and gurgles at a rate of 5 – 35 per minute. Note unexpected findings, such as increased or decreased bowel sounds or high-pitched tinkling sounds. Auscultate for three additional sounds (friction rubs, bruits, and venous hum) 1. Use the stethoscope diaphragm to detect high-pitched friction rubs over the liver and spleen 2. Use the stethoscope bell to check for bruits over the aortic, renal, iliac, and femoral arteries Key Point to Review - Abdomen STUDENT NOTES when you auscultate the abdomen? What is abnormal? 3. Use the stethoscope bell to assess for a soft, continuous, low-pitched venous hum in the epigastric area and around the umbilicus Abnormal: • Borborygmic: loud prolonged gurgles • Increased bowel sounds: gastroenteritis, early obstruction, hunger • High-pitched tinkling: intestinal fluid and air under pressure, early obstruction • Decreased bowel sounds: peritonitis, paralytic ileus • Absent bowel sounds for 5 minutes indicates abdominal pain and rigidity and is a surgical emergency Key Point to Review - Abdomen STUDENT NOTES Describe how you palpate the abdomen. What are you assessing when you perform light, moderate and deep palpation? What are the normal and abnormal findings? What do the abnormal findings indicate as possible differential diagnoses? Using light palpation, systematically assess all quadrants. But first, try to relax the abdominal muscles. For example, place a small pillow under the patient’s head and slightly flexed knees, warm your hands, take a slow and gentle approach, and save any tender areas for last. Press in no more than 1 cm with the palmar surface of your fingers • Expect the abdomen to feel smooth and soft • Note any resistance or tenderness. And watch for guarding, which should alert you to proceed with caution Using moderate palpation, systematically assess all quadrants in two ways. 1. Palpate with the palmar surface of your fingers. This may elicit tenderness that was not produced by light palpation 2. Palpate with the side of your hand throughout the respiratory cycle. As the patient inhales, you may feel the liver and spleen bump gently against your hand. Using deep palpation, systematically assess all quadrants with the palmar surface of your fingers. If a patient’s obesity or muscular resistance make deep palpation difficult, try bimanual palpation with one hand on top of the other. With either technique, feel for the rectus abdominis muscles, aorta, and portions of the colon. Note any tenderness. If you detect a mass, evaluate its location, size, shape, consistency, tenderness, pulsation, mobility, and movement with respiration. To see if the mass is superficial or intraabdominal, palpate as the patient lifts his or her head off the table. A superficial mass will remain palpable; an intraabdominal mass will not. Palpate the umbilical ring and periumbilical area. The umbilical ring should feel round and regular. The area should have no bulges, nodules, or granulation. Light Palpation: • Avoid problem spot areas • Palpate all 4 quadrants or all 9 regions Moderate Palpation: • Useful in assessing organs that move with respirations, liver, and spleen Deep Palpation: • Useful to detect less obvious masses, may use bimanual with one hand on top of the other for obese individuals Key Point to Review - Abdomen STUDENT NOTES Describe how and where you percuss the abdomen. What are normal and abnormal findings? What do the findings indicate? Systematically percuss for tone in all abdominal quadrants • Tympany is heard over the stomach and intestines • Dullness is heard over organs and solid masses Percuss to estimate the liver span, using 3 steps. 1. Determine the lower border of the liver by percussing up from an area of tympany along the right midclavicular line. Mark the point where tympany changes to dullness, which usually occurs at or slightly below the costal margin 2. Determine the upper border of the liver by percussing down from an area of resonance along the right midclavicular line. Mark the pint where resonance changes to dullness, which usually is in the fifth intercostal space. 3. Measure the distance between the marks. The vertical liver span usually ranges from 6 to 12 cm To assess liver descent, ask the patient to take a deep breath and hold it while you percuss the lower border again. With this maneuver, the area of dullness at the lower border should shift down to 2 to 3 cm. Percuss the spleen just posterior to the midaxillary line on the left side, beginning in areas of lung resonance and moving in several directions. You normally may hear a small area of splenic dullness from the sixth to ninth rib. Percuss the lowest intercostal space in the left anterior axillary line before and after the patient takes a deep breath. Tympany should remain in this area. Percuss for the gastric air bubble in the left lower anterior rib cage and left epigastric region. Gastric bubble tympany is lower in pitch than intestinal tympany. With the patient seated, percuss the kidneys, following two steps. 1. Place the palm of your hand over the right costovertebral angle and strike it with the side of the fist of your other hand. 2. Repeat this action on the left costovertebral angle. In both locations, the patient should feel a thud but no pain. Normal: • Tympany is normal sound d/t air present in stomach and intestines • Dullness heard over organs and solid mass • Always begin percussion over area of tympany and proceed to dullness • Liver dullness usually detected at 7th ICS Abnormal: • Lower liver boarder that is more than ¾ to1 inch below costal margin (under xiphoid process) may indicate organ enlargement or displacement of diaphragm d/t pulmonary disease • Spleen enlargement: tympany changes to dullness Key Point to Review - Abdomen STUDENT NOTES FYI 1. A tense abdomen could be a sign of inflammation. 2. Rigidity of the abdomen is a sign of peritoneal irritation. 3. A palpable tender gallbladder indicates cholecystitis, nontender enlargement suggests common bile duct obstruction. 4. As an inflamed gallbladder comes in contact with the examining fingers, the patient will experience pain and abruptly halt inspiration (Murphy’s sign). 5. Be careful when palpating the spleen. Patients with splenomegaly from infectious mononucleosis have a small risk for spontaneous splenic rupture. 6. A prominent lateral pulsation of the aorta suggests aortic aneurysm. How do you palpate for the various abdominal structures? What are the normal and abnormal findings? What do the findings indicate as possible differential diagnoses? Palpate for specific abdominal structures. • For the liver, press in and feel for its edge at the right costal margin as the patient takes a deep breath. If palpable, the liver should feel firm, smooth, even, and nontender. • For the gallbladder, palpate below the liver margin at the lateral border of the rectus abdominus muscle. A healthy gallbladder is not palpable. • For the spleen, press in over the left costal margin as the patient takes a deep breath. The spleen is not usually palpable. • For the kidneys, assess the right and left organs separately, placing one hand on the flank and the other hand on the costal margin. As the patient inhales deeply, lift the flank and palpate deeply. The right kidney is more commonly palpable than the left kidney. • For the aorta, palpate deeply for the aortic pulsation slightly left of the midline. If the pulsation is prominent, try to determine its direction. • For the bladder, palpate above the symphysis pubis. If the bladder is distended with urine, it feels like a smooth, round, tense mass. Normal: • Spleen, kidneys, and healthy gallbladder are not palpable Abnormal: • Cholecystitis: palpable tender gallbladder • Common bile duct obstruction: nontender enlarged gallbladder How do you assess for ascites? If a patient has ascites, what may that indicate? • If you suspect ascites, percuss the supine patient’s abdomen for dullness in the dependent parts and tympany in the upper parts. Also assess for shifting dullness or fluid wave. • Ascites: pathologic increase in fluid in peritoneal cavity. Most sensitive maneuvers for detecting ascites are flank dullness and presence of bulging flanks • If you suspect ascites, percuss the supine patient’s abdomen for dullness in the dependent parts and tympany in the upper parts. Also assess for shifting dullness or fluid wave suggests ascites. Key Point to Review - Abdomen STUDENT NOTES • If the patient reports abdominal pain, assess it thoroughly, especially its quality and location. When examining the abdomen, be sure to watch the patient’s face for clues to pain. If needed, assess for rebound tenderness and perform the iliopsoas muscle and obturator muscle tests. • If you suspect a freely movable abdominal mass, perform ballottement. How do you perform various advanced assessment techniques to assess for abdominal pain? Describe the positive and negative findings. What do the findings indicate as possible differential diagnoses? • If the patient reports abdominal pain, assess it thoroughly, especially its quality and location. When examining the abdomen, be sure to watch the patient’s face for clues to pain. If needed, assess for rebound tenderness and perform the iliopsoas muscle and obturator muscle tests. • Rebound tenderness: for peritoneal inflammation (press deeply and gently into the abdomen. Next rapidly withdraw the hands and fingers) • Iliopsoas muscle: for appendix suspension (the patient raises the leg from the hip while the examiner pushes downward against it) • Obturator muscle test: ruptured appendix/pelvic abscess – supine ask the patient to flex the right leg at the hip and knee to 90 degrees. Hold the leg just above the knee, grasp the ankle, and rotate the leg laterally and medially. (Pain in the right hypogastric region is a positive sign) • If you suspect a freely movable abdominal mass, perform ballottement (extend your fingers, hand and forearm at a 90 degree angle to the abdomen. Push in toward the organ or mass with the fingertips. If the mass is freely moveable, it will float upward and touch the fingertips as fluid and other structures are displaced by the maneuver) • Patients with abdominal pain don’t want area touches, are not hungry, if they point to specific point may mean greater significance Abnormalities: • Acute diarrhea: lasts less than 4 weeks, viral is most common cause, diffuse abdomen tenderness, lasts usually less than 2 weeks • GERD: backward flow of gastric contents, typically acidic in esophagus • IBS: disorder of intestinal mobility, 1/5 Americans, mostly woman, alternating constipation and diarrhea, mucus may be present, diagnosed after excluding other diagnosis • Hiatal hernia with esophagitis: part of stomach passes through esophageal hiatus in the diaphragm into chest cavity, common, occurs more often in women and older adults, epigastric pain, dysphagia • Duodenal Ulcer: chronic circumcised break in duodenal mucosa that scars with healing, may develop from infection – H. Pylori, abdominal pain • Crohn Disease: chronic inflammatory disorder that can affect any part of GI tract, Key Point to Review - Abdomen STUDENT NOTES terminal ileum and colon most common, unpredictable flares and remissions, RLQ pain, perianal skin tags are common and good clue for diagnosis • Ulcerative colitis: chronic inflammatory disorder of colon and rectum that produces mucosal friability and areas of ulceration: unknown cause but immunologic and genetic factors have been implied, bloody frequent watery stools, 20-30 diarrhea episodes a day, weight loss, fatigue • Stomach cancer: arises from epithelial cells of mucous membrane, most common in lower half of stomach, vague and nonspecific symptoms, loss of appetite, feeling full, eight loss, dysphagia, persistent epigastric pain, enlarged supraclavicular nodes • Diverticular disease: diverticula are saclike mucosal outpouching through colonic muscle, sigmoid is most common affected location. Diverticulitis: LLQ pain, anorexia, N/V, constipation • Colon Cancer: rectum, sigmoid, proximal, and descending colon, 2nd most common cancer in US, abdominal pain, bloody stool Hepatobiliary System Abnormalities: • Hepatitis: inflammatory process characterized by diffuse or patchy hepatocellular necrosis, caused by viral infection, alcohol, drugs, toxins, abnormal LFTs, asymptomatic or reports of jaundice, anorexia, abdominal pain, clay-colored stools • Cirrhosis: diffuse hepatic process characterized by fibrosis and alteration of normal liver architecture into structurally abnormal nodules, liver enlarged on exam, asymptomatic or some report jaundice, anorexia, abdominal pain, clay- colored stools • Primary Hepatocellular Carcinoma: associated with cirrhosis frequently, 6 months survival, jaundice, anorexia, fatigue, abdominal fullness, clay-colored stools, hard irregular liver palpated • Cholelithiasis: stone formation in gallbladder, crystals produced • Cholecystitis: inflammatory process of the gallbladder most commonly due to obstruction of the cystic duct from cholelithiasis, acute or chronic. RUQ pain radiating around the midtorso to right scapular region, pain abrupt and severe lasting 2-4 hours • Nonalcoholic fatty liver: spectrum of hepatic disorders not associated with excessive alcohol use, ranging from cirrhosis, steatosis, and hepato carcinoma, hepatic cell inflammation and injury thought to result from accumulation of triglycerides in the liver Pancreas: • Acute pancreatitis: acute inflammatory process in which release of pancreatic enzymes results in glandular autodigestion, epigastric pain that radiates to back, NV, abdominal distention, fever, anorexia • Chronic pancreatitis: atrophy, fibrosis, and pancreatic calcification changes, Key Point to Review - Abdomen STUDENT NOTES constant abdominal pain, weight loss, steatorrhea Spleen • Spleen laceration/rupture: most commonly injured organ, LUQ pain radiating to shoulder Kidney: • Acute glomerulonephritis: inflammation of the capillary loops of the renal glomeruli, edema, hypertension, oliguria or may have unremarkable findings, flank pain • Hydronephrosis: dilation of renal pelvis d/t obstruction of urine flow • Pyelonephritis: infection of kidney and renal pelvis: fever, dysuria, flank pain • Renal abscess: localized infection in medulla or cortex, same symptoms as pyelonephritis • Renal calculi: stones in pelvis of kidney, associated with obstruction and infections in the urinary tract, fever, dysuria, flank pain, hematuria • Acute Renal Failure: sudden impairment of renal function, urine output may be normal, decreased, or absent, may see fluid overload or dehydration Key Point to Review - Abdomen STUDENT NOTES Key Point to Review - Abdomen STUDENT NOTES Key Points to Review - Musculoskeleta l STUDENT NOTES What are some appropriate HPI questions you would ask a patient with a chief complaint of a musculoskeletal problem? Joint Symptoms • Character: stiffness or limitation of movement, change in size or contour, swelling or redness, constant pain or pain with particular motion, unilateral or bilateral involvement, interference with daily activities, joint looking or giving way • Associated events: time of day, activity, specific movements, injury, strenuous activity, weather • Temporal factors: change in frequency or character of episodes, better or worse as day progresses, nature of onset (slow versus rapid) • Efforts to treat: exercise, rest, weight reduction, physical therapy, heat, ice, braces or splints • Medications: NSAIDs, acetaminophen, biologic modifiers and other immunosuppressants, corticosteroids, topical analgesics; glucosamine, chondroitin, hyaluronic acid Muscular symptoms • Character: limitation of movement, weakness or fatigue, paralysis, tremor, tic, spasms, clumsiness, wasting, aching or pain • Precipitating factors: injury, strenuous activity, sudden movement, stress • Efforts to treat: heat, ice, splints, rest, massage • Medications: muscle relaxants, statins, salicylates, NSAIDs Key Points to Review - Musculoskeleta l STUDENT NOTES Skeletal symptoms • Character: difficulty with gait or limping; numbness, tingling, or pressure sensation; pain with movement, crepitus; deformity or change in skeletal contour • Associated event: injury, recent fractures, strenuous activity, sudden movement, stress, postmenopausal • Efforts to treat: rest, splints, chiropractic, acupuncture • Medications; hormone therapy, calcium; calcitonin, bisphosphonates Injury • Sensation at time of injury: click, pop, tearing, numbness, tingling, catching, locking, grating, snapping, warmth or coldness, ability to bear weight • Mechanism of injury: direct trauma, overuse, sudden change of direction, forceful contraction, overstretch • Pain: location, type, onset (sudden or gradual), aggravating or alleviating factors, position of comfort • Swelling: location, timing (with activity or injury) • Efforts to treat: rest, ice, heat, splints • Medications: analgesics, anti-inflammatory drugs Back pain • Abrupt or gradual onset • Character of pain and sensation: tearing, burning, or steady ache; tingling or numbness; location and distribution (unilateral or bilateral), radiation to buttocks, groin, or legs; triggered by coughing or sneezing and sudden movements • Associated event: trauma, lifting of heavy weights, long distance driving, sports activities, change in posture or deformity • Efforts to treat: rest, avoid standing or sudden movements, chiropractic, acupuncture • Medications: muscle relaxants, analgesics, anti-inflammatory drugs Describe how you would exam and inspect each region of the MS system including skin, muscles, bones and joints? What are normal and abnormal When examining each region, observe the following guidelines. • Inspect the skin and subcutaneous tissues over the muscles and joints, noting the skin color and number of skinfolds. Observe for any discoloration, swelling, or masses. • Inspect the muscles and compare contralateral sides for size and symmetry. Stay alert for gross hypertrophy or atrophy, fasciculations, and spasms. • Palpate the bones, joints, and surrounding muscles to evaluate muscle tone and detect any heat, tenderness, swelling, joint fluctuation, Key Points to Review - Musculoskeleta l STUDENT NOTES findings? crepitus, pain, or resistance to pressure. • Examine each major joint for active and passive range of motion. If the range of motion seems increased or decreased, use a goniometer to measure the angle at the joint. • Test muscle strength by applying resistance as the patient moves. Grade muscle strength from 0 (for no movement) to 5 (for full range of motion against gravity and full resistance). Normal: • Passive ROM exceeds active ROM by 5 degrees • Muscle strength should be equal bilaterally Abnormal: • Discrepancies between passive and active ROM may indicate true muscle weakness or joint disorder • Goniometer is used when joint appears to have an increase or limitation in ROM to measure the angle, measure flexion and extension • Muscle strength of 3 or less means disability is present Describe how you would examine, palpate, evaluate the range of motion and test the strength of the joints of the upper extremities. What are the normal and abnormal? What would the To examine the joints of the upper extremities, perform the following. Examine the hands and wrists in four ways. 1. Inspect the dorsum and palm of the hands. Note their contour, position, and shape and the number and completeness of fingers. 2. Palpate each joint in the hand and wrist. Joint surfaces should be smooth and without nodules, swelling, bogginess, or tenderness. 3. Test the range of motion. Metacarpophalangeal flexion should be 90 degrees. Metacarpophalangeal hyperextension should be 30 degrees. The patient should be able to demonstrate thumb opposition, form a fist, and adduct and abduct the fingers. You should see wrist flexion of 90 degrees and wrist hyperextension of Key Points to Review - Musculoskeleta l STUDENT NOTES abnormal findings indicate for possible differential diagnoses? 70 degrees. Expect radial motion to be 20 degrees and ulnar motion to be 55 degrees. 4. Evaluate muscle strength by testing wrist flexion and hyperextension and hand grip. • Heberden nodes: bony overgrowth in distal interphalangeal joints, hard nontender nodules • Bouchard nodes: proximal interphalangeal joints Assess the elbows with four methods. 1. Inspect the elbows in the flexed and extended positions. Note their contour and carrying angle, which should be 5 to 15 degrees laterally. 2. Palpate the extensor surface of the ulna, olecranon process, and medial and lateral epicondyles of the humerus. 3. Check the range of motion. With elbow flexion, range of motion should be 160 degrees. With extension, it should be 180 degrees. With pronation and supination, it should be 90 degrees. 4. Assess muscle strength during elbow flexion and extension. Evaluate the shoulders using four techniques. 1. Inspect the contour of the shoulders, shoulder girdle, clavicles, scapulae, and surrounding muscles. All shoulder structures should be symmetrical in size and contour. 2. Palpate the sternoclavicular joint, clavicle, acromioclavicular joint, scapula, coracoid process, greater tubercle of the humerus, biceps groove, and area muscles. 3. Examine range of motion. The patient should be able to shrug their shoulders, perform forward flexion to 180 degrees and hyperextension to 50 degrees, complete abduction to 180 degrees and adduction to 50 degrees, and do internal and external rotation of 90 degrees. 4. Test the muscle strength as the patient shrugs their shoulders. This maneuver also tests cranial nerve (CN) XI. Normal: • Painless movement, no nodules, no swelling, no tenderness Abnormal: • Deviation of the fingers to the ulnar side and swan neck or boutonniere deformities of the fingers usually indicates RA • A firm mass over the dorsum of the wrist may be a ganglion • Bony overgrowths in the distal interphalangeal joints, which are felt Key Points to Review - Musculoskeleta l STUDENT NOTES as hard, nontender nodules usually 2 to 3 mm in diameter but sometimes encompassing the entire joint, are associated with osteoarthritis • When located along the distal interphalangeal joints, they are called Heberden nodes • Those along the proximal interphalangeal joints are called Bouchard nodes • Painful swelling of the proximal interphalangeal joints causes spindle- shaped fingers, which are associated with the acute stage of RA • Cystic, round, nontender swellings along tendon sheaths or joint capsules that are more prominent with flexion may indicate ganglia • Elbow: • Subcutaneous nodules along pressure pints of the ulnar surface may indicate RA • Epicondylitis or tendonitis when a boggy, soft, or fluctuant swelling; point tenderness at the lateral epicondyle or along the grooves of the olecranon process and epicondyles; and increased pain with pronation and supination of the elbow are found Describe how you would examine, palpate, evaluate the range of motion and test the strength of the joints of the head and neck. What are the normal and abnormal findings? What would the abnormal findings indicate for possible differential diagnoses? To examine the joints of the head and neck, perform the following • Assess the temporomandibular joint in three ways 1. Palpate the joint space for clicking, pain, crepitus, locking, or popping 2. Assess range of motion by having the patient open and close their mouth, move the lower jaw to each side, and protrude and retract the jaw 3. Test the strength of the temporalis and masseter muscles with he patient’s teeth clenched. With this test, remember you are also evaluating CN V To examine the cervical spine using four techniques 1. Inspect the neck for alignment as well as symmetry of the skinfolds and muscles 2. Palpate the posterior neck, cervical spine, and paravertebral, trapezius, and sternocleidomastoid muscles 3. Evaluate range of motion by forward flexion (which should be about 45 degrees), extension (about 45 degrees), lateral bending (about 40 degrees), and rotation (about 70 degrees) 4. Test the strength of the sternocleidomastoid and trapezius muscles. This test also assesses CN XI Key Points to Review - Musculoskeleta l STUDENT NOTES Describe how you would examine, palpate, evaluate the range of motion and test the strength of the joints of the spine and hips? What are the normal and abnormal findings? What would the abnormal findings indicate for possible differential diagnoses? To examine the joints of the spine and hips, perform the following. • Assess the thoracic and lumbar spine with four maneuvers 1. Inspect the landmarks of the back for alignment. Note the curves of the spine. Remember that lordosis (or inward curvature of the spine) is common in patient who are obese or pregnant 2. Palpate along the spinal processes and paravertebral muscles 3. Percuss for spinal tenderness 4. Examine range of motion. Expect forward flexion of 75 to 90 degrees, hyperextension of 30 degrees, lateral bending of 35 degrees, and forward and backward rotation of the upper trunk of 30 degrees • Kyphosis: curved spine but alignment straight, common in older adults • Lordosis: common in obese and pregnant, lumbar spine curved inward • Scoliosis: lateral curvature Evaluate the hips in three ways 1. Inspect the hips, checking for symmetry, size of the buttocks, and numbers and level of the gluteal folds 2. Check the hip range of motion. Hip flexion with the knee extended should be 90 degrees; with the knee flexed, it should be 120 degrees. Hip hyperextension with the knee extended should be 30 degrees. Hip abduction should be 45 degrees, and adduction should be 30 degrees. Internal rotation should be 40 degrees, and external rotation should be 45 degrees. 3. Test the muscle strength during hip flexion with the knee flexed and then extended, during abduction and adduction, and when the seated patient uncrosses their legs. To examine the joints of the lower extremities, perform the following. • Assess the legs and knees using four techniques 1. Inspect the knees, their popliteal spaces, and lower leg alignment. The expected angle between the femur and tibia is less than 15 degrees 2. Palpate the popliteal space and tibiofemoral joint space, particularly noting tenderness, swelling, bogginess, nodules, or crepitus 3. Evaluate knee range of motion. Expect 130 degrees of flexion, full extension, and up to 15 degrees of hyperextension 4. Test the strength of the knee muscles while the patient maintains flexion and extension Examine the feet and ankles with four methods Key Points to Review - Musculoskeleta l STUDENT NOTES 1. Inspect the feet and ankles, while the patient is bearing weight and while sitting. Observe landmarks: contour; arches; foot alignment with the tibia; toe alignment with the other toes; and the position, size, and number of toes 2. Palpate the Achilles tendon, anterior surface of the ankle, medial and lateral malleoli, and each metatarsophalangeal joint 3. Check the range of motion with the patient seated. Dorsiflexion should be 20 degrees. Plantar flexion should be 45 degrees. Expect inversion of 30 degrees and eversion of 20 degrees. Expect abduction of 10 degrees and adduction of 20 degrees. Expect flexion and extension of the toes, especially the great toes 4. Test the muscle strength during dorsiflexion and plantar flexion and possible during ankle abduction and adduction and great toe flexion and extension Normal: • Joints should be without swelling, bogginess, tenderness, no nodules or crepitus Abnormal: • Excessive hyperextension of the knees with weight bearing may indicate weakness of quadriceps • Baker cyst: fullness in popliteal space • Hammer toe: hyperextension of metatarsophalangeal joint with flexion of the toes proximal joint • Mallet toe: flexion deformity at distal interphalangeal joint • Claw toe: hyperextension of metatarsophalangeal joint with flexion of toes proximal and distal joint • Hallux valgus: lateral deviation of great toe, may cause overlapping over 2nd toe • If bursa becomes inflamed it can form a bunion • An inflamed metatarsophalangeal joint of great toe may likely by gouty arthritis • Heat, redness, swelling, tenderness are all signs of joint inflammation: RA, gout, septic arthritis, fracture, tendonitis • Persistently thickened Achilles Tendon may indicate the tendonitis that can develop with spondyloarthritis or from xanthelasma of hyperlipidemia Shoulder: • Neer test: forward flex the patient’s arm up to 150 degrees while depressing the scapula. This presses the greater tuberosity and supraspinatus muscle against the anteroinferior acromion. Increased Key Points to Review - Musculoskeleta l STUDENT NOTES shoulder pain is associated with rotator cuff inflammation or a tear • Hawkins test is performed by abducting the shoulder to 90 degrees, flexing the elbow to 90 degrees, and then internally rotating the arm to its limit. Increased shoulder pain is associated with rotator cuff inflammation or a tear Lower Spine Assessment: • Straight leg raising test is used to test for nerve root irritation or lumbar disk herniation at the L4, L5, and S1 levels. Have the patient lie supine with the neck slightly flexed. Ask the patient to raise the leg, keeping the knee extended. No pain should be felt below the knee with leg raising. Radicular pain below the knee may be associated with disk herniation. • Femoral Stretch test: or hip extension test is used to detect inflammation of the nerve root at the L1, L2, L3, and sometimes L4 level. Have the patient lie prone and extend the hip. No pain is expected. The presence of pain on extension is a positive sign of nerve root irritation Hip Assessment: • The Thomas test is used to detect flexion contractures of the hip that may be masked by excessive lumbar lordosis. Have the patient lie supine; fully extend one leg flat on the examining table and flex the other leg with the knee to the chest. Observe the patient’s ability to keep the extended leg flat on the examining. Lifting the extended leg off the examining table indicates a hip flexion contracture in the extended leg • The Trendelenburg test is a maneuver to detect weak hip abductor muscles. Ask the patient to stand and balance first on one foot and then the other. Observing from behind, note any asymmetry or change in the level of the iliac crests. When the iliac crest drops on the side of the lifted leg, the hip abductor muscles on the weight-bearing side are weak Knee Assessment: • Ballottement is used to determine the presence of excess fluid or an effusion in the knee. • McMurray test is used to detect a torn medial or lateral meniscus. Have the patient lie supine and flex one knee. Position your thumb and fingers on either side of the joint space. Hold the heel with your other hand, fully flexing the knee, and rotate the foot and knee outward (valgus stress) to a lateral position. Extend and then flex the patient’s knee. Any palpable or audible click, grinding, pain, or limited Key Points to Review - Musculoskeleta l STUDENT NOTES extension of the knee is a positive sign of a torn medial meniscus. Abnormal: • genu valgum- knock-knee • Genu varum- bowleg • Genu recurvatum- excessive hyperextension of knees when wht bearing • herniated disks: caused by degenerative changes of the disk, L4, L5, and S1 most common • Lumbar stenosis: narrowing of spinal canal, pain with walking or standing • Gout: form of arthritis, disorder of purine metabolism that results from elevated serum uric acid level • Osteomyelitis: infection of bone • Bursitis: inflammation of bursa • Osteoarthritis: deterioration of articular cartilage covering the ends of bone in synovial joints • RA: chronic systemic inflammatory disorder of synovial tissue surrounding joints • Osteoporosis: decreased bone mass, bone resorption is more rapid than deposition, affects females more 4:1 • Crepitus indicates Special Procedures for assessment: Key Points to Review - Musculoskeleta l STUDENT NOTES • Strain involves muscle or tendon tearing or stretching • Sprain involves ligaments being tore or stretched Key Points to Review - Neurologic STUDENT NOTES What HPI questions do you ask a patient with a chief complaint of a neurological problem? Seizures or convulsions • Sequence of events (independent observer’s report): fall to ground, shrill cry, motor activity, transition phase, change in color of face or lips, pupil changes or eye deviations, loss of consciousness, loss of bowel or bladder control • Aura (perceptual sensation that may signal a seizure): irritability, tension, confusion, blurred vision, mood changes, initial focal motor seizure activity, gastrointestinal distress • Level of consciousness: loss, impairment, duration • Automatism: eyelid fluttering, chewing, lip smacking, swallowing • Muscle tone: flaccid, stiff, tense, twitching; where spasm began and moved through the body; change in character of motor activity during seizure • Postictal phase: weakness, transient paralysis, confusion, drowsiness, headaches, muscle aching, sleeping after seizure; any lateralization of signs • Relationship of seizure to time of day, meals, fatigue, emotional stress, excitement, menses, and discontinuing medications or poor compliance with medications; activity before episode • Frequency of seizures; total length of seizure activity; age at first seizure • Medications: anti-epileptic; initiation of medication or complementary or alternative therapy that interacts with prescribed anti-epileptic medication Pain: see Chapter 4 for general topics but consider “neurologic specific” pain such as headaches associated with meningitis or encephalitis, space-occupying lesions, neck pain, sciatica, or trigeminal neuralgia. • Onset: sudden or progressive, associated with fever or injury • Quality and intensity: deep or superficial; aching, boring, throbbing, sharp or stabbing, burning, pressing, stinging, cramping, gnawing, prickling, shooting; duration and constancy • Location or path: along distribution of one or more peripheral nerves or a more general distribution; radiating from one part to another • Associated manifestations: crying, change in activity or energy level, sweating, muscle rigidity, tremor, impaired mental processes or concentration, weakness • Efforts to treat and impact on life • Medications: opioids and nonsteroidal anti-inflammatory drugs; prescription, nonprescription Gait coordination • Balance: sensation of leaning when walking to doorway; unsteadiness when walking • Falling: fall one way, backward, forward, consistent direction; associated with looking up; legs simply give way; stiffness of limbs • Associated problems: arthritis of cervical spine or in knees, ataxia, stroke, seizure, arrhythmias, sensory changes Key Points to Review - Neurologic STUDENT NOTES • Medications: phenytoin, pyrimethamine, etoposide, vinblastine; prescription, nonprescription Weakness or paresthesia • Onset: sudden, or with activity initiation or following sustained activity, time before symptoms begin; rapid or slow • Character: generalized or specific body area affected (face, extremity); progressively ascending or transient; proximal or distal extremities, unilateral, bilateral, or asymmetrical; difficulty walking; loss of balance or coordination; hypersensitivity to touch or burning sensation • Associated symptoms: tingling or numbness; confusion, trouble speaking or understanding speech; severe headache; impaired vision in one or both eyes; limb feels encased in tight bandage, pain, shortness of breath, stiffness of joints, spasms, muscle tension, sensory deficits; loss of urinary or bowel control • Concurrent chronic illness such as human immunodeficiency virus (HIV) infection, diabetes, nutritional or vitamin deficiency, or recent acute illness • Medications: zidovudine, chemotherapy, HIV medications, amphotericin B Tremor • Onset: sudden or gradual • Character: worse with rest, intentional movement, or anxiety; unilateral or bilateral; body location (distal extremities, head); interference with daily activities and impact on life • Associated problems: hyperthyroidism, familial tremor, liver or kidney disorder, consumption of alcohol, multiple sclerosis • Relieved by: rest, activity, alcohol • Medications: neuroleptics, valproate, phenytoin, albuterol, pseudoephedrine, antiarrhythmics, corticosteroids, caffeine (all may cause essential tremor) How do you evaluate Cranial Nerve (CN) I (OLFACTORY NERVE)? What are the normal and abnormal findings? What do the abnormal findings For CN I (the olfactory nerve), test the patient’s ability to identify familiar odors, such as coffee and mint extract, one naris at a time with the eyes closed Normal: • The sense of smell may diminish with age Abnormal: • Inflammation of the mucous membranes, allergic rhinitis, and excessive tobacco smoking may all interfere with eh ability to distinguish odors. • Anosmia, the loss of sense of smell or an inability to discriminate odors, can be caused by trauma to the cribriform plate or by an olfactory tract lesion Key Points to Review - Neurologic STUDENT NOTES indicate as possible differential diagnoses? How do you evaluate CN II (OPTIC)? What are the normal and abnormal findings? What do the abnormal findings indicate as possible differential diagnoses? For CN II (the optic nerve), test visual acuity and the visual fields CN II is a measurement of central vision. • Snellen chart – distance vision. Have the patient cover one eye and read the smallest line on the Snellen chart in which he or she can identify all the letters. Record the visual acuity for that line, normally 20/20. Then have the patient cover the other eye and read the line from right to left. Timing can be tricky here: You want to do the test rapidly enough that the patient does not memorize the chart but not so fast that the patient feels rushed. • Rosenbaum – near vision. Have the patient hold the near-vision screener card about 35 cm from the eyes and read the smallest line possible. Record the visual acuity designated by that line. • Confrontation test – peripheral vision. Use the confrontation test. While positioned about 1 m away at eye level, have the patient cover the right eye while you cover your left. Look at each other. Move your wiggling fingers into the center from the side. Have the patient say when the fingers are first seen. Both of you should see them at the same time. Test the nasal, temporal, superior, and inferior fields. How do you evaluate CN II, IV and VI (OCULOMOT OR, TROCHLEAR , ABDUCENS)? What are the normal and abnormal findings? What do the abnormal findings indicate as possible differential For CN III, IV, and VI (the oculomotor, trochlear, and abducens nerves, respectively), assess the six cardinal point of gaze; inspect the eyelids for drooping, and observe the pupils for equality of size, shape and reaction to light and accommodation • Test visual fields by confrontation and extinction of vision • Inspect eyelids for drooping • Inspect pupils’ size for equality and their direct and consensual response to light and accommodation • Test extraocular eye movements To examine the extraocular muscles, perform the following. • Eye movement is controlled by six extraocular muscles and CNs III, IV, and VI. To evaluate eye movement, use the following four techniques. 1. Have the patient watch your finger move through the six cardinal fields of gaze. Sustained or jerking nystagmus should not occur. But keep in mind that a few beats of horizontal nystagmus may normally occur. 2. Have the patient follow your finger vertically from the ceiling to the floor. The globes and upper eyelids should move smoothly without eyelid lag or exposure of the sclera. 3. Test extraocular muscle balance using the corneal light reflex. With the Key Points to Review - Neurologic STUDENT NOTES diagnoses? patient looking at a nearby object, shine a light on the nasal bridge. The eyes should converge and reflect the light symmetrically. 4. If the corneal light reflex is imbalanced, perform the cover-uncover test. As the patient stares at a fixed point nearby, cover one eye and observe the uncovered eye. Then remove the cover and observe that eye as it focuses on the object. Note any eye movement. When assessing patients with severe, unremitting headaches, the experienced examiner evaluates movement of the eyes for the presence or absence of lateral (temporal) gaze. The sixth cranial nerve is commonly one of the first to lose function in the presence of increased intracranial pressure. How do you evaluate CN V (TRIGEMINA L)? What are the normal and abnormal findings? What do the abnormal findings indicate as possible differential diagnoses? For CN V (the trigeminal nerve), perform four assessments. 1. Inspect the face for muscle atrophy, jaw deviation, and tremors 2. Palpate the clenched jaw muscles for tone and strength 3. Test superficial pain and touch sensations in each branch of the nerve. If the results are unexpected, also test temperature sensation in these areas. 4. Test the corneal reflex How do you evaluate CN VII (FACIAL)? What are the normal and abnormal findings? What do the abnormal findings indicate as possible differential diagnoses? For CN VII (the facial nerve), observe for facial symmetry while the patient makes a series of facial expressions. Test the ability to identify tastes on the sides of the tongue Abnormal: • Drooping of one side of mouth, flattened nasolabial fold, sagging lower eyelid are signs of muscle weakness How do you For CN VIII (acoustic nerve), test the sense of hearing and bone and air conduction Key Points to Review - Neurologic STUDENT NOTES evaluate CN VIII (ACOUSTIC)? What are the normal and abnormal findings? What do the abnormal findings indicate as possible differential diagnoses? of sound and note sound lateralization How do you evaluate CN IX (GLOSSOPH ARYNGEAL)? What are the normal and abnormal findings? What do the abnormal findings indicate as possible differential diagnoses? For CN IX (the glossopharyngeal nerve), test the patient’s ability to identify tastes on the posterior third of the tongue How do you evaluate CN X (VAGUS)? What are the normal and abnormal findings? What do the abnormal findings indicate as possible For CN X (the vagus nerve), inspect the palate and uvula for symmetry with speech sounds. Check the gag reflex and the ability to swallow, keeping in mind that this also tests part of CN IX. Evaluate the patient’s speech sounds to detect any hoarseness, nasal quality, or difficulty with guttural sounds Key Points to Review - Neurologic STUDENT NOTES differential diagnoses? How do you evaluate CN XI (SPINAL ACCESSORY) ? What are the normal and abnormal findings? What do the abnormal findings indicate as possible differential diagnoses? For CN XI (the spinal accessory nerve), evaluate the size, shape, and strength of the trapezius and sternocleidomastoid muscles How do you evaluate CN XII (HYPOGLOS SAL)? What are the normal and abnormal findings? What do the abnormal findings indicate as possible differential diagnoses? For CN XII (the hypoglossal nerve), perform four assessments. 1. Inspect the tongue at rest and while protruded, noting symmetry, tremors, and atrophy 2. Observe tongue movement from side to side and toward the nose and chin 3. Test tongue strength by pressing your index finger against the check as the tongue presses against it from the inside. 4. Evaluate the quality of lingual speech sounds, such as l, t, d, and n • Any tongue fasciculations, asymmetry, atrophy, or deviation from the midline is unexpected Key Points to Review - Neurologic STUDENT NOTES Key Points to Review - Neurologic STUDENT NOTES Key Points to Review - Neurologic STUDENT NOTES How do you evaluate propriocepti on? What are the normal and abnormal findings? What do the abnormal findings indication for possible differential diagnoses? To assess proprioception and cerebellar function, perform the following. • Evaluate coordination and fine motor skills in two ways. 1. Observe as the seated patient performs rapid rhythmic alternating movements, such as patting the knees with both hands while alternating the palm and back of the hands. The movements should be smooth and rhythmic even with increasing speed 2. Watch for accuracy of movements, using the finger-to-finger test, finger- to-nose test, and heel-to-shin test on both sides of the body. Hand movements should be rapid, smooth, and accurate. The heel should move in a straight line with no deviations to the side • Evaluate balance by checking the patient’s equilibrium using four techniques 1. Perform the Romberg test. Have the patient stand with the eyes closed, feet together, and arms at the sides. Slight swaying is expected. During this test, remember to stand close by and be ready to catch the patient in case he or she starts to fall 2. Throw the standing patient off balance by pushing on the shoulders. The patient should quickly recover his or her balance. 3. Test for balance with the patient standing on one foot with the eyes closed and arms at the sides. The patient should maintain balance on each foot for 5 seconds, although slight swaying is expected 4. Have the patient hop in place on one foot and then the other. The patient Key Points to Review - Neurologic STUDENT NOTES should hop on each foot for 5 seconds without losing balance • Further evaluate balance by observing the gait with the patient’s eyes open and then closed. Look for the expected gait sequence, including posture and arm movements. The gait should have a smooth, regular rhythm and symmetrical stride length. The trunk posture should sway with the gait phase, and the arm swing should be smooth and symmetrical If you see an unexpected gait, have the patient perform heel-toe walking forward and back, with the eyes open and arms at sides. The patient should maintain consistent contact between the heel and toe but may sway slightly Abnormal: • A positive Romberg sign indicates cerebellar ataxia, vestibular dysfunction, or sensory loss. If the patient staggers or loses balance with the Romberg test, postpone other tests of cerebellar function requiring balance Unexpected Gait Patterns How do you See above Key Points to Review - Neurologic STUDENT NOTES evaluate cerebellar function? What are the normal and abnormal findings? What do the abnormal findings indication for possible differential diagnoses? How do you evaluate sensory function? What are the normal and abnormal findings? What do the abnormal findings indicate for possible differential diagnoses? To evaluate sensory function, perform the following • With the patient’s eyes closed, test these primary sensory functions. To test superficial touch sensation, lightly stroke the skin with a cotton wisp or the fingertip and have the patient identify the area touched. To assess superficial pain sensation, touch the skin with the sharp and smooth edges of a broken tongue blade and have the patient identify each sensation as sharp or dull and its location. Remember to allow 2 seconds between each stimulus to avoid a summative effect. If superficial pain sensation is not intact, test temperature sensation by rolling test tubes of hot and cold water on the skin. The patient should identify them correctly. Also test deep pressure sensation by squeezing the trapezius, calf, or biceps muscle, which should cause discomfort To check vibration sensation, place the stem of a vibrating tuning fork over several bony prominences on the upper and lower extremities. The patient should report and locate a buzzing or tingling sensation To evaluate joint position sensation, move the great toe or a finger up and down on each hand. The patient should accurately identify each movement • While the patient’s eyes are closed, test cortical sensory functions in five ways 1. Assess stereognosis by handing the patient a familiar object, such as a coin or key. Through touching and manipulating the object, the patient should be able to identify it 2. Evaluate two-point discrimination. Touch the skin with one or two sterile needles to determine the distance at which the patient can no longer distinguish two points Key Points to Review - Neurologic STUDENT NOTES 3. Elicit the extinction phenomenon by simultaneously touching the check or hand on each side of the body with the sharp edge of a broken tongue blade. The patient should feel similar sensations bilaterally 4. Assess graphesthesia by tracing a letter, number, or shape on the palm of the hand. The patient should be able to recognize it 5. Check point location by touching different areas of the body. The patient should point to the area you touched How do you test the reflexes? To test the reflexes, perform the following • Evaluate three superficial reflexes: the abdominal, cremasteric, and plantar reflexes To elicit the abdominal reflexes, stroke each quadrant with the end of a reflex hammer or the edge of a tongue blade. For the upper abdominal reflexes, stroke up and away from the umbilicus. For the lower abdominal reflexes, stroke down and away. Expect the umbilicus to shift toward the stroked side bilaterally and equally To test the cremasteric reflex, stroke the male patient’s inner thigh from the proximal to distal area. The testicle and scrotum should rise on the stroked side To check the plantar reflex, stroke the lateral side of the foot from the heel to the ball and then across the ball to the medial side. The expected response is plantar flexion of all toes Babinski sign indicates pyramidal tract disease • With the patient relaxed and seated or lying down, test five deep tendon reflexes. When using the reflex hammer, remember to tap briskly but not too forcefully. Score each reflex from 0 (for no response) to 4+ (for a hyperactive response with clonus). For the biceps reflex, hold your thumb over the biceps tendon and strike the thumb with the reflex hammer. This should cause elbow Key Points to Review - Neurologic STUDENT NOTES flexion For the brachioradial reflex, strike the brachioradial tendon (about 1 to 2 inches above the wrist) with the reflex hammer. The expected response is forearm pronation and elbow flexion For the triceps reflex, strike the triceps tendon directly, which should produce elbow flexion For the patellar reflex, strike the patellar tendon just below the patella. Expect to see lower leg extension For the Achilles reflex, strike the Achilles tendon at the level of the ankle malleoli. In response, the foot should plantar flex • Test for ankle clonus, especially if the reflexes are hyperactive. Briskly dorsiflex the patient’s foot and hold it in place. You should feel no clonus (or rapid, rhythmic contractions) Overall, if you find abnormal neurological findings, what additional procedures could you perform and why? When routine examination reveals problems, perform these additional procedures • Use 5.07 monofilament to test for protective sensation on the foot in patients with diabetes mellitus and peripheral neuropathy • Assess for meningeal signs by checking for a stiff neck with the supine patient’s head raised and by eliciting Brudzinski sign and Kernig sign: pain in lower back when attempting to straighten flexed knee while supine. • Jolt accentuation of headache: patient with fever and headache ask them to move head horizontally 2-3 rotations per second, positive sign indicated worse headache-potential sign for meningitis • Posturing: occurs with patients who are unresponsive with severe brain injury Disorders of Central Nervous System: • MS: progressive autoimmune disorder, inflammation and degeneration of myelin of brain’s white matter, leading to decreased brain mass and obstructed transmission of nerve impulses • Encephalitis: acute inflammation of brain and spinal cord involving meninges, often due to virus • Meningitis: inflammatory process in meninges, membrane around brain and spinal cord, 3 signs are altered mental status, nuchal rigidity, fever • Intracranial tumor: abnormal growth within the cranial cavity, persistent headache, n/v, confusion, unsteady gait • Pseudotumor cerebri: clinical syndrome of intracranial hypertension that mimics brain tumors • Stroke: loss of blood supply to part of the brain or ruptured blood vessels Disorders of Peripheral Nervous System: Key Points to Review - Neurologic STUDENT NOTES • Myasthenia Gravis: autoimmune disorder of neuromuscular junction involved with muscle activation, muscle dysfunction • Guillain-Barre Syndrome: post infectious disorder following a nonspecific GI or Resp infection that causes acute neuromuscular paralysis • Trigeminal Neuralgia: recurrent paroxysmal sharp pain that radiates into one or more branches of the 5th CN • Bell Palsy: temporary or acute paralysis of one side of face • Peripheral neuropathy: motor and sensory loss commonly caused by DM Key Points to Review - Mental Health STUDENT NOTES What questions do Depression • Troubling thoughts or feelings, constant worry; change in outlook on life or Key Points to Review - Mental Health STUDENT NOTES you ask a patient with a chief complaint of a mood disorder such as anxiety and depression? change in feelings; feelings of hopelessness; inability to control feelings • Low energy level, awakens feeling fatigued, agitation, feels best in the morning or at night • Recent changes in living situation, death or relocation of friends or family members, changes in physical health • Thoughts or plans for hurting self and/or others, thoughts about dying, hopelessness, no plans for the future • Medications: antidepressants; medications that may cause or worsen depression (e.g., antihypertensive agents, corticosteroids, beta-blockers, calcium channel blockers, barbiturates, phenytoin, anabolic steroids) Anxiety • Sudden, unexplained episodes of intense fear, anxiety or panic for no apparent reason; afraid will be unable to get help or will be unable to escape in certain situations; unable to control worrying; spends more time than necessary repeatedly doing or checking things • Feels uncomfortable in or avoids situations or events that involve being with people • Prior experience with a frightening or traumatic event • Associated symptoms: panic attacks, obsessive thoughts, or compulsive behaviors • Medications: antidepressants, steroids, benzodiazepines What are the Subjective Data • Alertness • Emotional status • Orientation: Time, Place, Person • Analogies (similarities) • Abstract reasoning (fable, proverb) • Arithmetic calculations • Writing ability • Motor skills • Memory: Immediate, Recent, Remote • Attention span (short commands) • Judgment/decision making (hypothetical situation) • Voice: Quality, Pace, Loudness • Articulation • Comprehension • Coherence (perceptions clearly conveyed) • Mood and feelings • Thought processes (logical) subjective data that you collect when you assess a patient's mental health in a primary care setting? Key Points to Review - Mental Health STUDENT NOTES • Perceptual distortions (hallucinations) Personal and Social History • Emotional status: feelings about self; anxious, restless, or irritable; discouraged or frustrated; problems with money, job, legal system, spouse, partner, or children; ability to cope with current stressors in life • Life goals, attitudes, relationship with family members • Intellectual level: educational history, access to information, mental stimulation • Communication pattern, able to understand questions, coherent and appropriate speech, change in memory or cognitive thought processes • Changes in sleeping or eating patterns; change in appetite or diet, weight loss or gain; decreased sexual activity • Use of alcohol or illicit drugs, especially mood-altering drugs What are the objective data that you collect when you assess a patient's mental health in a primary care setting? Objective Data Observation • Alertness • Grooming • Body language • Emotional status • Attention span • Coherence • Voice: Quality, Pace, Loudness • Articulation • Comprehension • Mood and feelings • Thought processes • Perceptual distortions Testing • Orientation: Time, Place, Person • Analogies • Abstract reasoning • Arithmetic calculations • Writing ability • Motor skills • Memory: Immediate, Recent, Remote • Attention span Key Points to Review - Mental Health STUDENT NOTES Mental status is assessed continuously throughout the entire interaction with a patient by evaluating the patient’s alertness, orientation, cognitive abilities, and mood. Observe the patient’s physical appearance, behavior, and responses to questions asked during the history. Note any variations in response to questions of differing complexity. Speech should be clearly articulated. Questions should be answered appropriately, with ideas expressed logically, relating current and past events. What is the difference between a patient's behavior with a diagnosis of dementia or delirium? Delirium • Impaired cognition, consciousness, mood and behavior dysfunction of acute onset Patho • Risk factors in older adults include serious illness or injury, impaired vision or hearing, or age-related changes in how medications are metabolized Subjective Data • Suspicious, fearful Key Points to Review - Mental Health STUDENT NOTES • Mood swings Objective Data • Altered consciousness • Incoherence, illogical flow of ideas • Illusions, hallucinations, delusions • Poor memory Dementia A mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for an extended period (weeks or longer) Patho • Associated with a neurochemical imbalance, a decreased level of monoamines, or increased plasma cortisol • Associated with stressful life event, grief, or change in lifestyle Subjective • Feels sad, hopeless, worthless • No interest or pleasure in what was previously of interest or pleasurable • Insomnia or excessive sleeping • Increased or decreased appetite Objective • Poor concentration • Slowed thought processes and speech • Agitation or restlessness Dementia: disordered speech, rambling, incoherent, depressed, uninterested Delirium: Rambling, rapid mood swings, fearful, suspicious, hallucinations, delusions Key Points to Review - Mental Health STUDENT NOTES How can you assess/test a patient's memory? If the patient has a poor recent memory, what are the possible differential diagnoses? Mental function as a whole may be evaluated in about 5 minutes with the Isaac Set Test. Ask the patient to name 10 items in each of four groups: Fruits, Animals, Colors, and Towns/cities (FACT) without prompting or rushing. The patient’s ability to respond demonstrates executive functioning, alertness, attention span, and recent memory. The patient has to categorize, count, name, and remember the items listed. Give each item 1 point for a possible total score of 40. Expect a score greater than 25. Dementia is associated with a score less than 15. Scores between 15 and 25 may