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
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
Responsiveness
• Hyperresponsive
– nonresponsive
• Increased impulsivity
– Lacking of impulse
• Cognitive style:
– Reflective: proceed slowly, fewer errors
– Impulsive style: respond quickly; more errors
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:
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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
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
• Concreteness leads to difficulties with
problem-solving---only see the simplest
solution!
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
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
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
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
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
Irritability and Low Frustration
Tolerances
• Pt may be prone to emotional outburst,
probably due to low frustration tolerance
• Different from emotional lability
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
SLP: Interviewing the patient
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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
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
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
Testing Brain Injured Patients:
• Increased levels of:
– Patience
– Empathy
– Understanding
• Expertise (experience) with test
administration and interpretation
• Observation rules for clinicians
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
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
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
Test Selection, cont.
• Test should suggest reasons for patient
performance
• Test should permit predictions about
recovery
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
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.
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?
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
Differential Diagnosis
• To “differentiate” among other
communicative disorders
• To label or not to label……….
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
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”
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
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
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 wellbeing
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
• 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?
Situations rated by the Communicative Effectiveness Index (CETI)
Item
Situation
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words
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involved
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Getting someone’s attention
Getting involved in group conversations about him/her
Giving “yes” and “ no” answers appropriately
Communicating his/her emotions
Indicating he/she understands what is being said to him/her
Having coffee, time visits and conversations with friends and neighbors
Having a one-to-one conversation
Saying the name of someone whose face is in front of him/her
Communicating physical needs such as aches and pains
Having a spontaneous conversation
Responding to or communicating anything (including “yes” or “no”) without
Starting a conversation with people who are not close family
Understanding writing
Being a part of a conversation when it is fast and there are a number of people
Participating in a conversation with strangers
Describing or discussing something at length