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Physical Assessment Part II Musculoskeletal, Mental Status, & Neurological Assessment

Physical Assessment Part II Musculoskeletal, Mental Status, & Neurological Assessment. PHCL 326 Hadeel Alkofide April 2011. Musculoskeletal System. Musculoskeletal System. Its evaluated mainly by two methods : Inspection Palpation. Musculoskeletal System. Inspection.

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Physical Assessment Part II Musculoskeletal, Mental Status, & Neurological Assessment

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  1. Physical Assessment Part IIMusculoskeletal, Mental Status, & Neurological Assessment PHCL 326 Hadeel Alkofide April 2011

  2. Musculoskeletal System

  3. Musculoskeletal System • Its evaluated mainly by two methods : • Inspection • Palpation

  4. Musculoskeletal System Inspection • Purpose: Assess function for ability to perform ADL’s • Inspect for symmetry, proportion, & muscular development • Observe gait, & ability to stand, sit, rise from sitting position, & grasp objects ADLs: Activities of Daily Living Routine activities such as getting dressed, cleaning the teeth, combing or brushing the hair, bathing & feeding oneself Gait: The way a person walks

  5. Musculoskeletal System Inspection • Inspect joints for symmetry, swelling, tenderness, & crepitation • Test muscle strength upper & lower extremities utilizing opposing force Crepitation: Audible or palpable crackling sound

  6. Musculoskeletal System Palpation • Palpate large & small joints • Assess range of motion (ROM) • Decreased ROM: Arthritis, fibrosis, tissue inflammation, & fixed joints • Increased ROM: Increased joint mobility & joint instability

  7. Musculoskeletal System Palpation • Limitation in ROM are expressed in degrees • Palpate joints & surrounding area for tenderness • Assess for warmth, crepitation, & deformities

  8. Neurological System

  9. Neurological System • Mental status • Cranial nerve function • Sensory & motor function • Reflexes

  10. Mental Status

  11. Mental Status

  12. Mental Status Physical: 1. Appearance • A summary of the physical presentation • Dress, facial expression • Posture, eye contact • Hygiene & Grooming • “Disheveled”- ruffled appearance • “Unkempt”- poor attention to grooming • Body habits, nourishment status • General description of body type/ build, & nutritional status

  13. Mental Status Physical: 2. Motor Activity • Quality & the types of actions observed • Reduction in the level of movement (psychomotor retardation) • Slowed movement (bradykinesia) • Decreased movement (hypokinesia) • Absence of movement (akinesia) • Increases in the overall level of movement (psychomotor agitation) • Tremor

  14. Mental Status Physical: 3. Behavior • Range & Frequency of Spontaneous Movements • Psychomotor activity • Abnormal movements • Psychomotorrefers to movements that appear driven from within, by one’s internal emotions at the time • Psychomotor Agitation, vs. • Psychomotor Retardation

  15. Mental Status Physical: 3. Behavior • Abnormal Movements • Automatisms- “automatic” involuntary movements; form of seizure • Ex. Lip-smacking, eye-blinking, staring • Mannerisms: goal-directed, complex behaviors carried out in an odd way or inappropriate context

  16. Mental Status Emotional: 1. Attitude • Patients may be: • Open, friendly, cooperative, willing, & responsive • Closed, guarded, hostile, suspicious & passive • Describe responses to questions, expression, posture, eye contact, tone of voice

  17. Mental Status Emotional: 2. Mood & Affect • Affect: an external expression of an emotional state is potentially observable • Mood: an internal emotional experience that influences perception of the world & behavioral responses

  18. Mental Status Emotional: 2. Mood & Affect Mood • Is the patient’s mood appropriate to situation? • Sad, Angry, Depressed, Anxious • Appropriate/Inappropriate

  19. Mental Status Emotional: 2. Mood & Affect Mood • Descriptors: euphoric, dysphoric, hostile, fearful, anxious, or suspicious • Stability of mood can also be noted, with the alternation between extreme emotional states being referred to as emotional lability

  20. Mental Status Emotional: 2. Mood & Affect Affect • Range, intensity, & variability of affect can be variously portrayed: • Restricted (i.e., low intensity or range of emotional expression) • Flat (i.e., absence of emotional expression) • Exaggerated (i.e., an overly strong emotional reaction)

  21. Mental Status Cognitive • Alertness • Attention & Cooperation • Orientation • Speech & Vocabulary • Memory • Insight & Judgment • Abstract Thinking • Calculation • Object Recognition • Praxis

  22. Mental Status.. Cognitive Alertness Level of Consciousness – LOC • Alert: Awake, answers questions • Lethargic: Sleeps when undisturbed, arouses to normal voice, answers questions appropriately –may be “fuzzy” • Obtunded: Sleeps most of time. Loud shout or vigorous shake to arouse. Mumbles • Stupor/Semi-coma: Responds only to pain stimuli. Mumbles, moves restlessly. Withdraws to avoid pain/noxious stimuli • Coma: Un-responsive to any stimulus

  23. Mental Status.. Cognitive Attention & Cooperation • Test attention by seeing if the patient can remain focused on a simple task, such as spelling a short word forward & backward (W-O-R-L-D / D-L-R-O-W is a standard) • These tests of attention depend on language, memory, & some logic functions as well • Degree of cooperation should be noted, especially if it is abnormal, since this will influence many aspects of the exam

  24. Mental Status.. Cognitive Orientation • Person, place, date/time, event • Time is the first to go, person the last. • Normal: Expressed as oriented x3 • Disoriented? All parameters or 1 or 2? • Does the patient re-orient? • Is this a change from baseline?

  25. Mental Status.. Cognitive Speech & Vocabulary • Have the patient repeat a specific phrase • Note his speech during the whole exam process • Clear, Slurred • Minimal (mostly "yes" and "no" answers, little volunteered information) • Talkative • Rapid/Pressured (as in possible hypomania or mania)

  26. Mental Status.. Cognitive Memory Immediate • Say a list of single digit numbers & ask patient to repeat them Short term • Have the patient memorize 3 unrelated words & ask him to repeat them later Long-term memory • Ask the patient about a known historical event that happened in his life time

  27. Mental Status.. Cognitive Insight & Judgment • Insight: a dimension that describes the extent to which patients are aware that they have a problem • Refers to an awareness of the nature & extent of the problem, the effects of their problem on others, & how it is a departure from normal • A strong lack of insight can be an important indicator of unwillingness to accept treatment

  28. Mental Status.. Cognitive Insight & Judgment • Judgment: The ability to make sound decisions can be compromised for a number of reasons • Ascertain if poor decisions are the result of problems in the cognitive processes involved in the decision making process, motivational issues, or failures to execute a planned course of action

  29. Professionalism • Six Tenets of Professionalism:  • Altruism        • Accountability • Excellence • Duty • Honor and Integrity • Respect for Others Accountability is the acknowledgment and assumption of responsibility for actions, products, decisions, and policies

  30. Neurological System • Mental status • Cranial nerve function • Sensory & motor function • Reflexes

  31. Neurological Assessment Cranial Nerve Function • There are 12 cranial nerves • Please refer to table 4-9 page 93 for assistance

  32. Neurological Assessment Cranial Nerve Function I - OLFACTORY • Don’t assess unless patient complains of loss of sense of smell or patient has a head injury • Don’t use a noxious stimulus • Ask him to close eyes & identify familiar odor one nostril at a time (Coffee, lemon) II - OPTIC • Visual acuity • Visual fields • Fundoscopic exam ( eye exam)

  33. Neurological Assessment Cranial Nerve Function III/IV/VI Oculomotor, Trochlear, Abducens • Size, shape of pupils, pupillary response • Eye movements • 9 cardinal positions V - Trigeminal • Motor - jaw strength: ask patient to clench teeth • Sense – ability to sense sharp, dull, hot cold, over front half of the face

  34. Neurological Assessment Cranial Nerve Function VII - Facial • Observe for facial asymmetry • Observe facial movements when the patient frowns, smiles, whistle, puffs out the cheeks & raises eyebrows • Test patient's ability to identify sweet, sour & salty tastes VIII – Acoustic • Test hearing

  35. Neurological Assessment Cranial Nerve Function IX/X - Glossopharyngeal, Vagus • Assess quality of speech • Assess gag reflex XI - Spinal Accessory • Test ability to shrug shoulders & turn the chin from side to side against resistance XII - Hypoglossal • Tongue strength (Stick out tongue) • Note abnormalities, asymmetry, deviation or atrophy

  36. Neurological Assessment Cranial Nerve Function Cranial Nerve Function Video

  37. Neurological Assessment Cranial Nerve Function For further assistance Please visit http://neuroexam.med.utoronto.ca/

  38. Neurological System • Mental status • Cranial nerve function • Sensory & motor function • Reflexes They will not be covered here

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