Evaluating the patient

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 • Active movement against resistance or gravity • Active movement against gravity but not resistance • Active movement only when gravity is eliminated • Flicker or trace of contraction • 0 No contraction

12. Deep (tendon) patellar Superficial Pathological (primititive) Gag Swallow Corneal Reflexes 0Absent 1+ Diminished 2+ Normal 3+ Brisk (faster, greater amplitude) 4+ Clonus (rhythmic contraction and relaxation

13. 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 Motor exam: common terms

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

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. 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 Types of seizures

21. MMSE Scoring (Folstein, Folstein & McHugh, 1975) 25-30 Normal Adult X < 25 = indication of compromised mental status (MMSE was on Judging Amy last week!)

22. 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