Advanced Health Assessment Notes PDF

ADVANCED HEALTH ASSESSMENT NOTES ON READINGS: **Unit one weeks 1 and 2** : Ch 1 an 2 from Physical examination, ch 1 from symptom to diagonisis **[CHAPTER ONE -- PHYSICAL EXAMINATION - APPROACH TO THE CLINICAL ENCOUNTER]** **CLINCAL SKILL --** Any discrete act within the overall practice of patie...

ADVANCED HEALTH ASSESSMENT NOTES ON READINGS: **Unit one weeks 1 and 2** : Ch 1 an 2 from Physical examination, ch 1 from symptom to diagonisis **[CHAPTER ONE -- PHYSICAL EXAMINATION - APPROACH TO THE CLINICAL ENCOUNTER]** **CLINCAL SKILL --** Any discrete act within the overall practice of patient care, singular elements that constitute clinical competence. ***Patient centered approach*** -- following the patients lead to understand their thoughts, ideas, concerns, and requests without adding additional information from the clinicians perspective ***Clinician centered approach*** -- focuses on what the clinician needs and not how the patient feels ***Disease/illness distinction model*** -- helps elucidate the perspectives of both the clinician and the patient **Disease** is the explanation the clinician uses to organize symptoms that leads to a clinical diagnosis **Illness** is a construct that explains how the patient experiences the disease **The Calgary-Cambridge Guides -- 5 major steps to a clinical encounter:** ***Initiating the session*** -- set the stage, adjust the environment, review the clinical record, set your agenda, greet the patient, identify patient -- title preferred pronoun ***Gathering information*** -- chief compliant or concern, "presenting problems", establish agenda -- what are your concerns today, how can I help you, Invite the patients story, gather information about the patient's perspective of their illness -- feelings, ideas, effect on function, expectations ***Physical examination*** ***Explanation and planning --*** Chunk and check (provide small chunks of info at a time and check for understanding), handouts, show me method ***Closing the session*** **[DISPARITIES IN HEALTHCARE:]** ***Social determinants of health*** -- conditions, in which people are born, grow, work, live, and age. And the wider set of forces and systems shaping the conditions of daily life. Economic stability, education, social and community context, health and healthcare, neighborhood ***Racism and Bias:*** ***Implicit bias*** -- a set of unconscious beliefs or associations that lead to a negative evaluation of a person on the basis of their perceived group identity. Can lead to a structural system of privilege called ***institutional bias*** that leads to misallocation of care ***Explicit bias*** -- conscious or deliberate decisions on preferences founded on beliefs, stereotypes or associations on the basis of a perceived group identity. ***Cultural Humility:*** Helps to mitigate implicit bias, promotes empathy, aids clinicians in acknowledging and respecting patients individuality. Defined as the process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners. Three dimensions: Self awareness, respectful communication, collaborative partnerships The 5 Rs: Reflection, Respect, Regard, Relevance, Resiliency Also consider a spirituality **[MEDICAL ETHICS:]** ***Nonmaleficence*** -- do no harm ***Beneficence*** -- act for the patients good by treating and preventing disease ***Respect for autonomy*** -- accept the choices patients with decisional capacity make about which treatments to undergo, including the right to reject treatment ***Decisional capacity*** -- ability to make an autonomous choice that clinicians should respect ***Confidentiality*** Informed consent -- elicit patients voluntary and informed authorization to test or treat them for illness or injury ***Truth telling*** ***Justice*** ***[How to resolve an ethical] dilemma*** -- state the question, collect the facts, patient preferences, concerns, quality of life, identify the ethical principals and guidelines, delineate and relate options to values and principles, evaluate the options, make an action plan. **[CHAPTER TWO- PHYSICAL EXAMINATION -- INTERVIEWING, COMMUNICATION, AND INTERPERSONAL SKILLS]** **[FUNDAMENTALS OF SKILLED INTERVIEWING:]** ***Active or attentive listening*** -- connecting to patients emotional state, carefully listening ***Guided questioning*** -- show sustained interest in patients feelings, several techniques: Moving from open-ended to focused questions -- going from general to specific. Avoid leading questions. Ask questions that required a graded response as opposed to just yes or no (example --how many steps can you climb without getting out of breath instead of do you get short of breath when climbing steps Ask a series of questions one at a time "do you have any of the following problems" Offer multiple choice answers -- which of the following words best describes your pain Clarify what the patient means -- request clarification when needed Encourage with continuers -- nods, neutral utterances Echoing -- repeat patient's last words ***Empathetic Responses*** -- recognize the patient's feelings, move toward, and elicit emotional content ***Summarization*** -- give a capsule summary of patient's story ***Transitions*** -- tell patient when you are moving to a different topic ***Partnering*** -- Express commitment to the relationship ***Validation*** -- validate the legitimacy of the patient's emotional experience ***Empowering the patient*** -- evoke the patients perspective, convey interest, follow the patients leads, elicits and validate emotional content, share information with the patient, make clinical reasoning transparent, reveal limits of your knowledge ***Reassurance*** -- identify and acknowledge the patients feelings **[APPROPRIATE VERBAL COMMUNICATION:]** Use understandable language Use non stigmatizing language **[APPRPOPRATE NON-VERBAL COMMUNICATION:]** Forms include -- body orientation towards the patient and proximity, gaze, head nodding, gestures, posture, tone and use of voice, use of silence, use of touch (haptics) The most important rule is to be NON JUDGEMENTAL **[INFORMED CONSENT:]** Communication process in which a clinician educates a patient about the risks, benefits, and alternatives of a given procedure or intervention Required elements are: Nature of procedure or treatment, risks and benefits, reasonable alternatives, risks and benefits of alternatives, assessment of the patients understanding of the elements Must make sure patient has decisional capacity or if not, who is their healthcare proxy **[WORKING WITH A MEDICAL INTERPRETER:]** Use short, concise questions directed towards the patient "How long have you been sick", make sure the interpreter is aware of the plan for the visit/call, thank them, do NOT use family members **[ADVANCED DIRECTIVES:]** It is important to encourage all adults especially those who are ill to have an advanced directive and a health care proxy or healthcare power of attorney to act as the patients decision maker if they are incapacitated. For patients who are clinically frail or at end of life -- ***POLST/MOLST form*** -actionable medical order form that tells others the patients' medical orders for life sustaining treatment DNR/ALLOW NATURAL DEATH -- mandatory to ask about for cardiac and pulmonary resuscitation for acutely ill, hospitalized patients **[DISCLOSING SERIOUS NEWS:]** SPIKES PROCESS S -- Setting up the interview P -- Assess the patients PERCEPTION I -- Obtain the patients INVITATION -- find out how much the patient wants to know K -- giving KNOWLEDGE and information to the patient E -- address the patients EMOTIONS and provide EMPATHETIC responses S -- STRATGEY and SUMMARY **[MOTIVATIONAL INTERVIEWING:]** Set of well documented techniques that improve health outcomes Invite patient to talk and explore their feelings, listen more than you talk, be sensitive, don't jump to conclusions, ask permission to give feedback, summarize to the patient what you are hearing, value the patients opinion **[INTERPROFESSIONAL COMMUNICATION:]** SBAR -- SITUATION, BACKGROUND, ASSESSMENT, RECOMMENDATION **[CHALLENGING PATIENT SITIUATIONS AND BEHAVIORS:]** ***Silent --*** be attentive and ask "you are quiet, what are you thinking about", be aware of how many questions you are asking, ask if you have upset the patient ***Talkative*** -- be patient, set time limits, ask them to come back for another visit to go over more issues if necessary ***Confusing narrative*** -- Try to guide the interview into a psycho social assessment ***Altered state or cognition*** -- seek best-informed source, determine if patient has decision-making capacity ***Emotional liability*** -- offer a tissue, wait for patient to recover, encourage patient ***Angry/Aggressive*** -- validate feelings, if aggressive alert security, stay calm ***Flirty patient --*** ANY romantic relationship with a patient is unethical, make sure to have a chaperone in room if necessary ***Discriminatory patient*** -- assess illness of patient, remove self if necessary ***Hearing loss*** -- find out patients preferred method of communication, if they belonged to deaf culture or hearing culture when hearing loss occurred, sit on hearing side if deaf in one ear ***Low or impaired vision*** -- shake hands to establish contact, explain surroundings ***Limited intelligence*** -- assess level of understanding ***Personal problems*** -- let patient talk ***Nonadherent*** -- try to find out why, help set up schedule and overcome barriers ***Low literacy*** -- assess patients ability to read ask how comfortable they are filling out forms, be sensitive ***Low health literacy*** -- assess abilities ***Limited language proficiency*** -- use medical interpreter ***Terminal illness/Dying --***Understand patients fears and concerns, empathize, address your own feelings about death, recognize the stages of loss: denial and isolation, anger, bargaining, depression or sadness, acceptance. The goal is prevention and relief of suffering **[CHAPTER ONE -- SYMPTOMS TO DIAGNOSIS:]** ***Diagnostic process*** -- often called clinical reasoning Errors in reasoning account for 17% of all adverse events **Dual reasoning processes** are used to work through a case ***System 1 reasoning*** -- based on pattern recognition and involves matching a patients presentation to an illness script, a prior example stored in memory. Used more with experienced clinicians and straightforward cases ***System 2 reasoning*** -- slower process using an explicit analytic approach. Used more with less experienced clinicians and complicated cases Many times both types are blended **[MODEL FOR CLINICAL REASONING:]** ***Step one -- identify the problem*** - Construct a complete problem list consisting of chief compliant, other acute symptoms, and physical exam abnormalities, lab test abnormalities, chronic active problems, important past problems Problem lists should begin with the acute problem followed by chronic active problems ***Step two -- frame the differential diagnosis --*** Should be framed in a way that facilitates recall -- use problem specific framework to organize the differentials into subcategories that are easier to remember and clinically useful. They can be: Anatomic -- often used for chest pain Organ system -- used for symptoms with very broad differentials such as fatigue Physiologic or based on Pivotal points ***Step three -- organize the differential diagnosis --*** Use pivotal points -- one a pair of opposing descriptors that compare and contrast clinical characteristics Examples -- old vs new headache ***Step four*** -- limit the differential diagnosis -- using pivotal points, create a patient specific differential diagnosis to help narrow the list ***Step five -- Explore possible diagnosis using history and exam findings*** -- look for clinical clues, focus on positive findings. Some very specific findings are called FINGERPRINT FINDINGS because they are rarely seen in patients without the disease. Use FP as the symbol for this type of finding ***Step six -- rank the differential diagnosis --*** four approaches to doing this: **Possibilistic approach** -- consider all known causes equally likely and test for all of them at same time. NOT USEFUL **Probabilistic approach** -- consider those diagnosis that are more likely first -- those with the highest *pretest probability* -- the probability that a disease is present before further testing is done **Prognostic approach** -- consider the most serious diagnosis first **Pragmatic approach** -- consider the diagnosis most responsive to treatment first ***Step seven -- Test your hypotheses*** -- order the tests ***Step eight-*** re-rank the differential based on new data ***Step nine*** -- test the new hypotheses **[THE THRESHOLD MODEL: CONCEPTUALIZING PROBABLILITIES:]** The ends of the bar in the threshold model represent 0-100% pretest probability ***Treatment threshold*** -- the probability above which diagnosis is so unlikely it can be excluded without further testing Diagnostic tests are necessary when the pretest probability is in the middle, above the test threshold and below the treatment threshold. A very useful tests shifts the probability of disease so much that the posttest probability crosses one of the thresholds **[UNDERSTANDING TEST RESULTS]** ***Test characteristics*** can help determine the probability of false results. They are determined by performing the rest in patients known to have or not have the disease and recording the distribution of results. ***Sensitivity*** -- the % of patients with true positive results ***Specificity*** -- the % of patients with true negative results ***Likelihood ratio*** -- the likelihood that a given test result would occur in a patient with the disease compared to the likelihood that the same result would occur in a patient without the disease. A positive likelihood ratio indicates that the result is likely a true positive. ***+ LR over 1.0*** indicate that a true positive is much more likely than a false + **UNIT TWO: Chapters 4,5,8, and 9 from Physical Examination** **[CHAPTER 4: PHYSICAL EXAMINATION:]** **[COMPREHENSIVE ADULT PHYSICAL EXAMINATION:]** Head to toe exam, source of fundamental and personalized knowledge about the patient \*\*\*A focused exam targets a specific problem To begin the comprehensive exam make sure you: *Reflect on approach to patient* *Adjust lighting and environment* *Check your equipment* *Make the patient comfortable* -- ensure privacy and proper positioning, provide courteous and clear instructions, keep patient informed ***Observe standard and universal precautions and if needed contact, droplet, airborne, or reverse isolation*** Contact -- gloves and gown (c.diff, MRSA) Droplet -- gloves, gown, mask -- Covid, Flu, whooping cough Airborne -- gloves, gown, respirator mask -- TB, Chickenpox Reverse -- protects patient gloves, gown, mask ***Chose sequence, scope, and positioning of examination:*** The four CARDINAL TECHNIQUES -- inspection, palpation, percussion, auscultation **INSPECTION** -- close observation of the details of the patient's appearance, behavior and movement Facial expression, mood, skin condition, eye movements, pharyngeal color, gait, edema, etc **PALPATION** -- Tactile pressure from the palmar fingers or finger pads to assess areas of skin elevation, depression, warmth, tenderness, lymph nodes, pulses, contours and sizes of organs and masses and any crepitus in joints **PERCUSSION** -- Use of the striking "PLEXOR FINGER" -- generally the third finger to rapidly tap or blow against the distal pleximeter finger -- usually the third distal finger of the left hand laid against the surface of the chest or abdomen to evoke a sound wave **AUSCULTATION** -- Use of the diaphragm and bell of the stethoscope to detect the characteristics of heart, lung, and bowl sounds including location, timing, duration, pitch, and intensity. For heart -- sounds from closure of 4 valves, extra sounds from blood flow into the atria and ventricles, and murmurs. Can also detect bruits and turbulence. **SEQUENCE OF EXAM:** Exam patient from their RIGHT side -- estimates of jugular pressure are more reliable, right kidney is usually more palpable than the left ***Patient sitting up***: general survey, vital signs, skin, head and neck, thorax and lungs, breasts, optional -- cranial nerves, motor strength ***Lying supine:*** Head of bed 30 degrees, Cardiovascular -- jugular venous pressure, carotid upstrokes and bruits, murmurs ***Lying fully supine:*** Breasts and axillae, abdomen, peripheral vascular, nervous system -- lower extremity motor strength, reflex, babinski's reflex ***Sitting/Standing:*** Musculoskeletal as indicated Move from head to toe ***General survey*** -- overall appearance, state of health ***Vital signs*** ***Skin-*** assess skin moisture or dryness, identify lesions, inspect hair and nails ***Head, Eyes, Ears, Nose, Throat --*** ***Head*** -- examine the hair, scalp, skill, and face ***Eyes --*** visual acuity and screen the visual fields, compare pupils, inspect ocular fundi ***Ears*** -- inspect and check auditory acuity, if diminished perform a weber test to check laterization and a Rinne test to check bone conduction ***Nose and sinuses*** -- look at mucosa ***Throat/Mouth/Pharynx*** -- lips, oral mucosa, gums, teeth, tongue, palate, and pharynx -- can also assess the cranial nerves during this portion of the exam ***NECK*** -- inspect and palpate the cervical lymph nodes and thyroid gland ***BACK*** -- Spine and muscles of the back ***POSTERIOR THORAX AND LUNGS --***Inspect and palpate the spine and muscles of the UPPER back, inspect, palpate, percuss the chest. Listen to breath sounds ***BREASTS AND AXILLAE*** -- In women inspect the breasts with arms relaxed, then elevated, then hands pressed on hips. In both sexes -- inspect axillae and feel for the axillary nodes ***ANTERIOR THORAX AND LUNGS***: Inspect, palpate, and percuss the chest. Listen to breath sounds. ***CARDIOVASULAR SYSTEM:*** Observe the jugular venous pulsations and measure the jugular venous pressure in relation to the sternal angle. Inspect and palpate carotid pulses, listen for carotid bruits. Note location of apical impulse. ***ABDOMEN -*** Inspect, auscultate, then percuss the abdomen. Palpate lightly then deeply, assess the liver and spleen by percussion THEN palpation, try to palpate the kidneys ***LOWER EXTREMITIES*** -- Examine legs while patient is still supine, if necessary have patient stand to further assess: ***Peripheral vascular system*** -- palpate femoral pulses and if indicated the popliteal pulses, palpate the inguinal lymph nodes, inspect for lower extremity edema, discoloration, ulcers. Palpate for pitting edema ***Musculoskeletal*** system -- note any deformities or enlarged joints, check range of motion.While patient STANDS -- check alignment of legs, feet, spine, range of motion ***NERVOUS SYSTEM:*** ***Mental status*** -- assess orientation, thoughts, mood ***Cranial nerves*** -- sense of smell, strength of temporal and masseter muscles, corneal reflexes, facial movements, gag reflex, strength of trapezia and sternocleidomastoid muscles, fundusopic exam if not done yet. ***Motor system***- assess muscle bulk, tone, and strength for major muscle groups ***Cerebellar system*** -- rapid, alternating movements (RAMS), point to point movements -- finger to nose and heel to shin ***Sensory system -*** assess pain, temperature, light tough, vibration, and discrimination, compare each side. ***Reflexes*** -- biceps, triceps, brachuiradialis, patellar, Achilles, deep tendon, plantar or Babinski reflexes **[ADDITIONAL EXAMS]** Done at end of exam. For men, genital and rectal should be lying on left side, for women should be in supine in lithotomy position **[CHAPTER 5: CLINICAL REASONING, ASSESSMENT, AND PLAN:]** Once the physical exam and history are completed, it is time to start formulating a ***differential diagnosis.*** **[CLINICAL REASONING PROCESS:]** ***Dual Processing System 1 or Intuitive System*** -- fast and automatic reaction to information that functions on mental shortcuts called ***heuristics*** which are formulaic response patterns based on formed habits. These are hard to change or manipulate ***System 2 Hypotheticodeductive System*** -- more tempered and controlled thought process. Subject to conscious judgements and attitudes. Uses logic and probabilities to come to conclusions. Time and resource intensive ***Basic structures of the clinical reasoning process*** -- gather initial patient information, organize and interpret the information, generate a hypothesis (differential diagnosis), test the hypothesis, plan the diagnostic and treatment strategy The goal is to create a concise and appropriate problem representation which is known in the clinical record as a ***summary statement*** Select a ***working diagnosis*** -- one that fits the patient's problem the best **[Gather initial patient information]** -- health history and physical exam **[Organize and interpret the clinical information] --** Cluster the information and analyze one cluster at a time. Can cluster by: Anatomic location -- example -- scratchy throat Age Timing -- when did symptoms start Involvement of different body issues -- can help group clinical data Multisystem Conditions -- can help come up with plausible explanations for a patient's symptoms **[Synthesize clinical information and develop the problem representation] --** this is the clinicians evolving sense of the clinical picture, contains the patient's initial information, key features in h&p, and results of diagnostic testing \****The development of a well-developed and concise problem representation guides a clinician to generating a hypothesis and developing the differential diagnosis.*** **[Generate hypotheses by searching for the probable cause of the findings:]** Generate exhaustive list Match findings against all conditions that can produce them Eliminate diagnostic possibilities that fail to explain the findings Weigh competing possibilities and select the most likely diagnosis Give special attention to potentially life threatening conditions **[Test the hypotheses and Establish a working diagnosis:]** Establish a working definition of the problem at the highest level of explicitness and certainty that the data allow **[Plan the diagnostic and treatment strategy ]** Important to make sure the patient understands and agrees with the plan **[CLINICAL DIAGNOSTIC ERRORS]** Common sources: ***Anchoring bias*** -- lock into the salient features in the patients initial presentation too early in the process and failure to adjust in light of new information ***Availability heuristic*** -- Assumption that a diagnosis is more likely or more frequent if it readily comes to mind ***Confirmation bias*** -- seeking supporting evidence for a diagnosis at the exclusion of more persuasive information refuting it ***Diagnostic momentum*** -- prioritizing a diagnosis made by prior clinicians which discounts the evidence of alternative explanations ***Framing effect*** -- Interpretation of information is influenced heavily by how the information about the problem is presented ***Representation error*** -- failure to take prevalence into account when estimating the probability of a diagnosis ***Visceral bias*** -- Visceral arousal -- both negative and positive feelings towards patient can lead to poor diagnostic decisions -- example -- homeless patient and clinician assumes they wont be able to follow treatment plan so gives less effective plan instead without talking about the options with the patient. **[DOCUMENTATION:]** ***Summary statement*** -- chief complaint placed in context of patients overall health status Includes pertinent parts of the H&P and lab data Succinct and short -- 2-3 sentences Demonstrates clinical reasoning skills Makes a case for the diagnosis Is a distillation of your understanding of the case Includes ***SEMANTIC QUALIFIERS*** -- qualifying adjectives: Acute At rest, with activity Constant, intermittent Diffuse, localized Mild, severe Old, new Sharp, dull Unilateral, bilateral Young, old **[ASSESSMENT AND PLAN]** List in order of priority and expanded upon with explanation of findings and a differential diagnosis -- then a plan for addressing the problem The health maintenance section helps to track immunizations, education, and screenings **[CHAPTER 8 --GENERAL SURVEY, VITAL SIGNS, AND PAIN:]** ***Constitutional symptoms*** -- patient concerns that accompany many disease processes Examples -- chills, weakness, fever, night sweats, fatigue, weight change, pain ***Fatigue and weakness*** - ***fatigue*** is a non-specific symptom with many causes. Is a common symptom of anxiety and depression but can also signal infections, endocrine issues, kidney and liver issues, electrolyte imbalances, anemia, malignancy, nutritional issues, and medication issues ***Weakness*** -- demonstrable loss of muscle power ***Weight change*** -- rapid changes can indicate changes in the body fluid, not the body tissue Clinically significant weight loss is loss of 5% or more of usual body weight over a 6 month period ***Pain*** -- One of the most common symptoms in the office practice. Most frequent case is low back pain, headache/migraine, knee and neck pain **PATIENT HEIGHT AND WEIGHT:** ***Stadiometers*** -- accurate measurement tool for height For weight -- make sure patient wears similar clothing each time to measure accurate weight, BMI=weight inkg/height, can use the online BMI calculator BMI: Underweight -- less than 18.5 Normal -- 18.5-24.9 Overweight 25-29.9 Obesity Level 1 30-34.9 Level 2 35-39.9 Level 3 -- extreme greater than or equal to 40 VITAL SIGNS -- use a **sphygmomanometer, many different things can impact bp, some common things that impact it are:** Acute meal ingestion and acute alcohol ingestion -- can lower readings at first Acute caffeine use, smoking, bladder distention, cold, paretic arm, white coat -- can all increase ***Procedure related*** -- insufficient rest period, legs crossed at knees, unsupported arm, arm lower than heart, talking during measurement, cuff size too small -- **can all show higher readings** Stethoscope under cuff and fast cuff deflation can ***show higher than normal systolic, lower diastolic***, large cuff size, ***can show lower*** Unsupported back and excessive pressure on stethoscope head can ***show higher diastolic readings*** **[ACUTE AND CHRONIC PAIN:]** Pain is an unpleasant sensory and emotional experience associated with tissue damage. **ACUTE PAIN** -- normal, predicted physiological response to an adverse chemical, thermal, or mechanical stimulus **CHRONIC PAIN** -- pain not associated with cancer or other medical conditions that persists for more than 3-6 months, pain lasting more than 1 month beyond the course for acute illness or injury, or pain recurring at intervals of months or years **Different types of pain:** ***Nociceptive (SOMATIC) pain*** -- linked to tissue damage to the skin, musculoskeletal system, or viscera. Sensory nervous system is intact. Can be acute or chronic. Mediated by the afferent A-delta and C-nerve fibers of the sensory system Described as DULL, PRESSING, PULLING, THROBBING\< BORING, SPASMODIC, or COLICKY ***Neuropathic Pain*** -- direct consequence of a lesion or disease affecting the somatosensory system. Can become independent of the injury over time. CNS or Spinal cord injuries, entrapment, peripheral nervous system issues, referred pain ELECTRIC SHOCK LIKE, STABBING, BURNING, PINS and NEEDLES **[SCREENING FOR HYPERTENSION:]** ***Primary hypertension --*** Most common kind, factors include age, weight, genetics, black race, obesity and weight gain, excessive salt, excessive alcohol, physical inactivity ***Secondary hypertension*** -- less than 5%, causes include obstructive sleep apnea, chronic kidney disease, renal artery stenosis, medications, thyroid disease, parathyroid disease, cushings, hyper alodsteronism, and coarctation of the aorta. For patients with hypertension recommend increased intake of foods high in potassium -- baked potatoes, white beans, beet greens, soybeans, spinach, lentils, kidney beans, yogurt, tomato paste juice puree and sauce, bananas, dried fruits, plantains, orange juice Reduce intake of high sodium foods -- canned foods, pretzels, chips, pizza, pickles, olives, processed foods, batter friend foods, table salt **[CHAPTER 9 --COGNITION, BEHAVOIR, AND MENTAL STATUS:]** ***Key Neurotransmitters involved in mental disorders:*** ***Serotonin --*** located in the brainstem -- raphe nuclei, helps regulate mood, arousal, cognition ***Norepinephrine*** -- located in the brainstem, locus coeruleus --regulates mood, arousal, attention, and cognition ***Dopamine*** -- located in the brainstem -- substantia nigra -- regulates mood, arousal, cognition, and motor control ***Acetylcholine*** -- located in the basal forebrain -- basal nucleus of Meynert -- regulates sleep, arousal, and attention It is very important to let patients know that mental health disorders are real and treatable just like any other issue to help to remove the stigma. ***Common/Concerning Symptoms:*** **Anxiety or excessive worrying** -- generalized anxiety disorder, social phobia, panic disorder, PTSD, acute stress disorder. Ask about nature of worry "Over the past 2 weeks have you been feeling nervous, anxious, on edge?" "Over past 2 weeks have you been unable to stop worrying?" "Over past 4 weeks, have you had an anxiety attack?" **Depressed mood --**major depressive disorder, persistent depressive disorder, bipolar disorders, disruptive mood disorders, premenstrual dysphoric disorder Risk factors include family history, chronic illness, childhood adverse events **Memory problems** -- Dementia and delirium fall under neurocognitive disorders ***Dementia*** -- major cognitive disorder ***Mild cognitive disorder*** -- less severe level of cognitive impairment that applies to younger patients with impairment from TBI or HIV **Medically unexplained symptoms** **Look at patients appearance and behavior including:** **[LEVELS OF CONSCIOUSNESS]** **Alert --**eyes open, meets gaze, responds fully **Lethargy** -- appears drowsy, opens eyes when spoken to in a loud voice, responds to questions then falls asleep **Obtundation** -- Opens eyes with tactile stimulus, responds slowly and is confused **Stupor** -- arouses with painful stimuli, slow or absent verbal responses, unresponsive once stimulus is removed **Coma** -- no response **[SPEECH AND LANGUAGE]** Quantity -- is patient talkative or unusually quiet? Rate and Volume -- is speech fast or slow, loud or soft? Articulation of words -- are words clear and distinct? Fluency -- rate, flow, and melody of speech, abnormalities include: Hesitancies and gaps in the flow and rhythm of words **Circumlocutions** -- phrases or sentences are used in replacement of a word the patient cannot think of. Example -- The thing that you write with **Paraphasias** -- words are malformed "I write with a den", incorrect "I write with a bar", or invented "I write with a dar" If patient's words lack meaning or fluency, then do an **Aphasia test:** Word comprehension -- ask patient to follow a one stage command, example "Point to your nose", then a two stage command "point to your mouth and touch your knee" Repetition -- ask patient to repeat a phrase of one-syllable words -- can be very hard. Example" No ifs, ands or buts Naming -- ask patient to name parts of a watch Reading comprehension -- ask patient to read a paragraph out loud Writing -- ask patient to write a sentence **[MOOD]** Pervasive and sustained emotion that colors the persons perception of the world **[THOUGHT]** ***Thought process*** -- the logic, organization, coherence, and relevance of the patients thought as it leads to selected goals, there can be variations and abnormalities: ***Blocking*** -- sudden interruption of speech in midsentence or before the idea is complete "lost thought", happens to many people ***Circumstantiality*** -- mildest thought disorder -- speech with unnecessary detail, indirection, and delay in reaching the point, this is also normal ***Clanging*** = speech with choice of words based on sounds --rhyming and punning ***Confabulation*** -- fabrication of facts or events in response to questions to fill in gaps from impaired memory ***Derailment*** -- loosening of association -- tangential speech without shifting topics that are loosely connected or unrelated. Patient NOT aware of lack of association ***Flight of ideas*** -- an almost continuous flow of accelerated speech with abrupt changes from one topic to another. Changes based on understandable associations, plays or words, or distracting stimuli. Thoughts are not well connected ***Incoherence*** -- incomprehensible speech, illogical ***Neologisms*** -- Invented or distorted words ***Preservation*** -- persistent repetition of words or ideas ***Thought content*** -- what the patient thinks about including level of insight and judgement. To assess this, follow the patient's leads and cues rather than asking direct questions. Abnormalities include: ***Anxieties*** ***Compulsions*** ***Delusions*** -- false fixed personal beliefs that are not amenable to change in light of conflicting evidence Persecutory, grandiose, jealous, ertomanic, somatic, unspecified ***Depersonalization*** -- sense that one's self or identity is different, changed, unreal, lost, detached ***Derealization*** -- sense that the environment is strange, unreal, or remote ***Obsessions*** ***Phobias*** **[PERCEPTIONS:]** Sensory awareness of objects in the environment and their interrelationships. Also refers to dreams or hallucinations **[COGNITIVE FUNCTIONS:]** Orientation is the awareness of personal identity, place, and time -- requires both memory and attention Attention -- ability to focus Digit Span -- repeat a series of digits, starting with two at a time at a rate of one per second, if patient can repeat back try a series of three numbers, then four, ert Serial 7s Spelling backward Memory -- process of registering or recording information Remote/long term Recent/Short term **[UNIT THREE: PHYSICAL EXAMINATION CHAPTERS 11, 12, 13, 14, DIAGNOSTIC CHAPTERS 20 AND 30]** **[CHAPTER 11: HEAD AND NECK]** HEAD: Two paired salivary glands lie near the mandible: Parotid Gland -- superficial to, and behind the mandible, the opening of this duct is called the Stensen duct Submandibular gland -- deep to the mandible Both are visible when englarged  The superficial temporal artery is easily palpable just in front of the ear **NECK**: To help with descriptive purposes, divide the each side of the neck into 2 triangles bounded by the sternocleidomastoid (SCM) muscle\ ***Anterior cervical*** triangle -- the mandibulae above, the SCM muscle laterally, and the midline of the neck medially ***Posterior cervical triangle*** -- the SCM muscle, the trapezius, and the clavicle  **GREAT VESSELS** -- Deep to the SCM muscles The carotid artery and the internal jugular vein \*note that the external jugular vein passes diagonally over the surface of the SCM, can be helpful when trying to identify jugular venous pressure  **[\ ]**