Evaluating the patient

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Scientific Method. Identify the problemPropose a solution: formulate a hypothesisDevelop procedures to test eh hypothesisCollect data relevant to the hypothesisAnalyze the dataModify the hypothesis, formulate a new one or reach a conclusion based upon the analysis. Scientific method as a clinical method.

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Evaluating the patient

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1. Evaluating the patient

2. Scientific Method Identify the problem Propose a solution: formulate a hypothesis Develop procedures to test eh hypothesis Collect data relevant to the hypothesis Analyze the data Modify the hypothesis, formulate a new one or reach a conclusion based upon the analysis

3. Scientific method as a clinical method Gather information about the patients impairment; referral, hx., examination Evaluate the subjective reports (“symptoms”) and objective test results (“signs”) for which are actually relevant Decide if a collection of symptoms and signs exists: syndrome

4. Seek relationships among symptoms and signs so as to know the involvement of the body or the mental status If the symptoms are a syndrome that has a known course and outcome, state a prognosis for eventual recovery From the hs, examination and facts, formulate a decision on how the patient’s condition will affect daily life

5. Things to remember about clinical methods Data collection and analysis is basically using the scientific method to solve a specific problem: finding a clinical solution Learn from experiences: the process repeats itself! The process is ongoing; constant changes occur, therefore routinely re-evaluate Missing “data” leads to flaws in diagnosis

6. Referrals Personal information Pts. location at the time of the referral Short description of current status Referral source

7. Reviewing medical records Patient ID Personal history: occupation, marital status, children, residence, hobbies, employment and educational history Medical Hx.: previous illnesses, injuries, medical conditions, current disabilities, complaints.

8. Communication issues: previous CVAs, disorientation, confusion, distorted sph, loss of consciousness, seizures, chronic medical conditions e. g., diabetes, vascular disease, heart disease, pulmonary disease, hearing loss, visual problems

9. Neurologic Examination Cranial nerves Motor system: Muscle tone and range of movement: Hypertonia: increased resistance to passive movement---2 forms Spacticity (increased stretch reflex causes muscles to be hard and tense)---motor cortex or corticspinal tract---UMN Rigidity (relaxed limb evenly resists movement in any direction Extrapyramidal system lesions---LMN

10. Decreased resistance to passive movement: Hypotonia (flaccidity)—”rag doll phenomena”

11. Muscle Strength

12. Reflexes Deep (tendon) patellar Superficial Pathological (primititive) Gag Swallow Corneal

13. Motor exam: common terms Athetosis: slow, writing movements; involuntary & purposeless—basal ganglia/ex-pyr. Sys. Dystonia: abnormal, involuntary contractions or postures Myoclonus: short bursts; cause abrupt, brief movements; cerebellar Fasciculations (muscle) & Fibrillations (muscle fiber) Both are LMN indicators

14. Common terms Gait: walk Festinating gait: running, tiny shuffling walk—Parkinson’s Steppage gait Waddling Dancing gait

15. Sensory system examination Evaluation to somesthetic (bodily) senses: pain, numbness or abnormal sensations Hyperesthesia: abnormal sensitivity to stimulation Paresthesia: disturbance in peripheral nerves Anesthesia: complete loss of sensation

16. Sensory system exam Pain, pressure, touch Deep sensation: muscles, tendons and joints Body position and vibration Superficial sensation: skin Light touch, pinprick, and temperature

17. Sensory: Equilibrium Dizziness: Vertigo VIII nerve lesions (acoustic neuroma) Vascular problems of brainstem or cerebellum Meniere’s disease (increased pressure in the inner ear: Vestibular system) Evaluated by stance, gait, and nystagmus

18. Consciousness and Mentation Confusion: lowered overall level of consciousness Lethargy: drowsy, may fall asleep at inappropriate times Amnesia: complete loss of memory for a time. Note Post Traumatic Amnesia (PTA)

19. Seizures Note frequency, duration, precipitating events, and changes in sensation or mentation (“aura”), NOTE: physical status AFTER the seizure General causes: alcohol or drug withdrawal, CNS infections, hypoglycemia, and other diseases

20. Types of seizures Gran Mal: “convulsion” Massive discharge of neurons in brain causes contraction of all muscles in the body Last about 1-3 minutes Petit mal = brief loss of consciousness < 1 min. Bilateral brain dysfunction Partial Seizures “Focal seizures” localize discharge on neurons Partial loss of consciousness Fleeting duration Clonic movements of individual muscle groups Localized brain dysfunction

23. Behavioral and Cognitive Changes of Brain Damage Presence of these changes are dependent upon: Previous Personality and Intellect Location and extent of injury Psychosocial support system Such complications can compound the evaluation process

24. Responsiveness Hyperresponsive nonresponsive Increased impulsivity Lacking of impulse Cognitive style: Reflective: proceed slowly, fewer errors Impulsive style: respond quickly; more errors

25. Perseveration Repetition of responses that are no longer appropriate Frequency and persistence of the behavious depends on the severity of the BD May be seen in: Unilateral injury to either hemiphere Generalized damage due to TBI Middle stages of dementia Usually occurs in the first few days/weeks following the injury

26. Cognitive Changes Concreteness and abstraction difficulties Concrete: “loss of abstract attitude” Unable to understand literal meanings Difficulty with metaphors and idioms Difficulty with humor, sarcasm, proverbs May contribute to BD pts. Egocentrism---can’t accept another point of view

27. Concreteness leads to difficulties with problem-solving---only see the simplest solution!

28. Impaired Self-Monitoring Pt’s have difficulty recognizing their own performance in structured or unstructured circumstances May fail to recognize errors in treatment, inappropriate behavior in social situations Usually in pts with diffuse BD than those with focal lesions More often infrontal or temporal lobe lesions

29. Impaired Error Anticipation Some pts. Recognize their errors but cant’ anticipate or prevent them Posterior lesions: usually find it funny Anterior lesions: usually dismayed by the error

30. Impaired Focus and Concentration Slow to focus implies pt performance improves with time Difficulty holding concentration implies performance will deteriorate over time Note pattern for when an activity changes

31. Impaired Sequencing Difficulty perceiving, retaining, reporting and reproducing sequential information Temporal sequencing????? Pointing, in order to a series of objects or pictures Often found in frontal lobe damage in the language dominant hemisphere

32. Disturbances of Personality and Emotion Emotional Lability: BD maylead to exaggerated swings in emotional expression The emotion is correct but the magnitude of the reaction is disproportionate to the stimulus May be expressed as uncontrolled crying Pseudobulbar affect: failure to suppress a primitive reflex May be expressed as excessive laughter---especially if pt feels stressed or threatened

33. Irritability and Low Frustration Tolerances Pt may be prone to emotional outburst, probably due to low frustration tolerance Different from emotional lability

34. Intolerance vs. Lability Frustration has visible early signs Progressive state of agitation Reaction can be diverted if one recognized the signs Lability happens rapidly Dissipates rapidly A reaction to one event

35. SLP: Interviewing the patient Find a quiet spot with few distractions Include a family member, if possible Tell the patient who you are!!! Make the patient physically comfortable Get the patient’s side of the story Be patient; listen carefully Talk at the level of the patient; avoid jargon

36. More on interviewing Do your homework ahead of time! Treat the patient as an adult; treat with respect Prepare the patient for what is going to happen

37. Ok, it’s time for testing….. Explain the purpose of the testing Describe the type of tests to be administered Explain how the information will be analyzed and how it will be protected Explain the test procedures ASK the patient how he/she feels about taking ANY test

38. Testing Brain Injured Patients: Increased levels of: Patience Empathy Understanding Expertise (experience) with test administration and interpretation Observation rules for clinicians

39. General guidelines for testing Do your homework Choose an appropriate location for testing Schedule testing at a time to maximize the patient’s performance Make the testing process collaborative Select appropriate tests

40. Test Selection A sample of a large # of performances at different levels of difficulty Test should locate a performance that is error-free, an area of complete breakdown and several intervening levels Standardized test: so that results are reliable from test to test

41. Test Selection, cont. Test should consistently input modalities, cognitive processes used, and output modalities needed to complete the test instructions Test responses should be recorded in terms of quality and correctness Test items should be sufficient to permit reliable estimates of performance

42. Test Selection, cont. Test should suggest reasons for patient performance Test should permit predictions about recovery

43. Guidelines, cont. Use patient’s performance as a guide for what and how you test. Use standardized tests and test procedures if you want to generalize the patient’s behavior to others or to other test administrations Evaluate the normative sample of the test Evaluate the normative statistics of the test

44. Considerations for Standardized Testing Reliability: can it be repeated with the same result? Inter-rater reliability Intra-rater reliability Validity Content validity: how well does the content of a test related to known theory, models or concepts; Construct validity: are the content and test procedures relevant to theory, etc.

45. Guidelines, cont. Get a large enough sample of patient’s overall communicative behavior to allow for test-retest comparisons Read the manual; consider the norm group and sample size Generally: bigger sample size is better—why?

46. Reasons for SLP testing To diagnose a communication disorder To determine a prognosis for the CD To make decisions on management and focus of the CD To measure either the recovery process or the efficacy of the treatment process

47. Differential Diagnosis To “differentiate” among other communicative disorders To label or not to label……….

48. Establishing a prognosis “Prognosis” is a prediction about the course of the recovery and about the extent of the recovery-----must consider: Neurologic findings: stroke recovery patterns Associated conditions: general vs. Impaired health, sensory and motor involvement Patient variables: age, gender, education, occupation, premorbid intellingence, handedness, personality and emotional state

49. Prognosis, cont. Nature and severity of the communication impairment(s) For example, Broca type aphasics are better predictors of recovery than Wernicke’s---why? Consider the predictive validity of some standardized tests. Minnesota Test for Differential Diagnosis of Aphasia (MDTTA) uses a “patient profile approach”

50. Predictive validity, cont. Porch Index of Communicative Ability (PICA) uses a statistical prediction method Uses statistical analyses to determine the “relative” contributions of some variables HOAP slope: High-overall prediction)---uses the 9 highest scores of the 18 subtests as a predictor of recovery Prognostic treatment as a precursor to stating a prognosis

51. Treatment Efficacy Single subject design is an excellent means of establishing baseline performance levels -for measuring patients’ response to treatment For cues to the clinician to change tx. Procedures For evaluating generalization of behaviors For contributing to our knowledge base on neurogenic communication disorders

52. Efficacy and Functional Outcome Efficacy: whether treatment has a positive effect As measured on a standardized test Outcome: whether tx. provided meaningful benefit Functional outcome: tx improves patient’s daily life competences or personal well-being

53. Therefore, In SLP, functional communication is an “approach to assessment and treatment that focuses on the patients’ daily life communicative success or lack thereof.” (Brookshire) Communication is not dependent on precise messages (linguistic) but upon the exchange of ideas despite errors in phonlogy, syntax, word choice, etc.-----function of language, not form

54. Promoting Aphasics’ Communicative Effectiveness (PACE) Davis and Wilcox, 1985) Focuses on daily-life communications and on socially relevant aspects of communication In health care, “functional communication” means: able to communicate basic needs and wants---what does that mean to you?

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