Download Evaluating the patient

Evaluating the patient
Scientific Method
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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
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
• 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
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
Referrals
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Personal information
Pts. location at the time of the referral
Short description of current status
Referral source
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.
• 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
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
• Decreased resistance to passive movement:
– Hypotonia (flaccidity)—”rag doll phenomena”
Muscle Strength
4 Active movement against resistance or gravity
3 Active movement against gravity but not
resistance
2 Active movement only when gravity is eliminated
1 Flicker or trace of contraction
0 No contraction
Reflexes
• Deep (tendon)
– patellar
• Superficial
– Pathological
(primititive)
• Gag
• Swallow
• Corneal
0 Absent
1+ Diminished
2+ Normal
3+ Brisk (faster,
greater amplitude)
4+ Clonus (rhythmic
contraction and
relaxation
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
Common terms
• Gait: walk
– Festinating gait:
running, tiny shuffling
walk—Parkinson’s
– Steppage gait
– Waddling
– Dancing gait
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
Sensory system exam
• Pain, pressure, touch
– Deep sensation: muscles, tendons and joints
• Body position and vibration
– Superficial sensation: skin
• Light touch, pinprick, and temperature
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
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)
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
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
MMSE Scoring
(Folstein, Folstein & McHugh,
1975)
25-30 Normal Adult
X < 25 = indication of
compromised mental
status
(MMSE was on Judging
Amy last week!)
Personal history: Mr. Shaw is a 55-y/o accountant (college grad). Married, with two children; son 28, daughter neither living at home. Wife
(Florence) is a secondary-school teacher. Nonsmoker x 10 yrs. Occasional social ETOH nonabuser. Both parents deceased (mid-80s),
apparently of natural causes. Employed at time of apparent neurologic incident. Medical history: Past medical history includes adult-onset
diabetes mellitus diagnosed in 1991, hypertension diagnosed 1993, and a possible TIA in March of last year. The patient's wife reports that at
the time of the apparent TIA they were watching television when the patient became confused, did not answer questions, and seemed not to
understand. The patient's symptoms apparently cleared in an hour or two, and they did not seek medical advice or assistance. Medications
on admission include tolbutamide 500 mg twice a day, chlorothiazide 500 mg twice a day, which apparently control the patient's
hypertension and diabetes, and occasionally aspirin. Background: The patient was accompanied to this medical center by his wife, who
provided this information. The patient apparently was in good health until this apparent neurologic event, which occurred at approximately
0815 hrs this day. The patient was getting dressed for work when he experienced a sudden onset of speech difficulties and leg weakness. The
patient did not vomit, lose consciousness, or report double vision, nausea or vertigo. He arrived at the emergency room ( medical center at
0905 hrs. The neurologic examination began at approximately 0920 hrs. Habits: The patient is an ex smoker (0.5 ppd x 10 years) and has not
smoked for approximately the past 10 years. The patient apparently drinks three or four glasses of wine per week and other alcoholic drinks
occasionally, but his wife reports that he has never been a heavy drinker. Physical examination: The patient looks his stated age and is in no
apparent distress. He appears alert and is oriented x 3. Vital signs: Blood pressure 162/89, pulse 72, temperature 98.6, respiration 18.
HEENT exam: No signs trauma or deformation. Moist mucous membranes. Neck negative for lymphadenopathy or thyromegaly. No carotid
bruit. Cardiovascular exam: Normal S 1, 52, without gallop or murmurs. Lungs: Clear to auscultation. Abdomen soft land nontender. No
organomegaly or palpable masses. Lower extremities: No pedal edema. Neurologic examination: The patient is globally aphasic. Listening
comprehension evaluation showed that he is able to follow very simple commands like "close your eyes" or "open your mouth." He is unable
to give yes-no answers to questions. He is a little bit confused as to right/left commands. He is unable to do complex commands. Reading
evaluation showed the patient unable to to identify a letter. He had paraphasic errors in single-word identification (e.g., "wrisp" for "wrist").
The patient was unable to follow commands on reading because of inability to comprehend. Expression evaluation showed that the patient
unable to read a narrative. He was unable to repeat "no ifs, ands, or buts." He was also unable to name objects like watch or pin. Cranial
nerve examination: It was difficult to examine the patient's visual acuity because of his aphasia. Acuity appears within normal limits, but
the patient exhibits a questionable right-sided field cut. Funduscopic examination showed no evidence of papilledema. His pupils are 3mm to
4 mm bilaterally, round, equal, and reactive to light and accommodation. He had intact extraocular movements. His corneal relexes are
present bilaterally. His jaw jerk was + 1 .He had symmetrical nasolabial folds and wrinkles. His tongue is midline and so is his uvula. He has
symmetrical gag reflex bilaterally. He has symmetrical strength in his shoulders bilaterally. Motor examination: The patient has no pronator
drift and no involuntary movements. His muscle tone is normal bilaterally. His strength appears 5/5 on the left and 4/5 in the right upper
extremity and 3/5 in the right lower extremity. Grasp reflex on right. He had external rotation in his right lower extremity. His coordination
exam was unremarkable for dysmetria. Deep tendon reflexes are +2 on the left and +3 on the right, + 1 in both ankles. Plantar reflex on right.
Sensory examination: Impossible to establish accurately because of patient’s aphasia. However, the patient withdraws both lower and upper
extremities to pinprick stimuli. Gait: The patient walks slowly, but with symmetrical arm swings bilaterally. Mild dragging of right foot.
Problem list: 1 .Probable LH stroke 2. Aphasia 3. Hypertension 4. A~-onset diabetes mellitus