Musculoskeletal Neuro Assessment PDF

Musculoskeletal Assessment: =========================== Objectives - Identify the key landmarks of each joint. - Obtain an accurate history of the MSK system. - Complete an accurate physical assessment of the musculoskeletal system including **inspection and palpation of the joints, bo...

Musculoskeletal Assessment: =========================== Objectives - Identify the key landmarks of each joint. - Obtain an accurate history of the MSK system. - Complete an accurate physical assessment of the musculoskeletal system including **inspection and palpation of the joints, bones, and muscles, range of motion of the major joints, and assessment of muscle strength using the grading scale.** - Identify risk factors for osteoporosis. - Discuss health promotion strategies to reduce risk for osteoporosis, low back pain, and falls. **Common or Concerning Symptoms** - Joint pain - associated with systemic symptoms, such as fever, chills, rash, weakness, and weight loss. - Low back pain - Neck pain - Bone pain - Muscle pain or cramps or weakness **Obtaining the Health History** +-----------------------------------+-----------------------------------+ | **General:** | **Terms:** | | | | | - Ask the pt if they are | - **Dislocation**: | | experiencing pain in joints, | | | bones or muscles | - one or more bones in a | | | joint being out of place. | | - **Myalgias**: muscle pain | | | | - **Subluxation**: | | - **Arthralgias**: joint pain | | | | - partial dislocation of a | | - Any complaints of pain, | joint. | | discomfort → assess further | | | using OLDCART | - **Contracture**: | | | | | - Self-care behaviors present | - shortening of a muscle | | exercise | leading to limited ROM of | | | joint. | | - Medications | | | | | | - Treatments | | | | | | **Low Back Pain: COMMON!!** | | | | | | - Is pain on the midline | | | | | | - Over the vertebrae | | | | | | - Off the midline | | | | | | - Radiation | | | | | | - Numbness or Paresthesias | | | | | | - Associated bladder or bowel | | | dysfunction | | | | | | **Neck Pain** | | | | | | - Radiation to arm | | | | | | - Arm or leg weakness or | | | paresthesias | | | | | | - Any changes in bladder or | | | bowel function | | | | | | - Patients with persistent pain | | | after blunt trauma or a motor | | | vehicle accident require a | | | referral to a | | +-----------------------------------+-----------------------------------+ Examination ----------- +-----------------------------------+-----------------------------------+ | **Examination of the | **Muscle bulk** | | Joints** | | | | - Inspect size and contour | | - Inspect joint symmetry, | | | alignment, & any bony | - Atrophy? | | deformities. | | | | - Hypertrophy? | | - Inspect and palpate | | | surrounding tissues for skin | - Fasciculations? | | changes, nodules, muscles | | | atrophy, & crepitus. | - Spasms, tremors that can | | | happen | | - Assess range of motion (ROM) | | | to test joint function & | - Involuntary | | stability. | | | | | | - Assess for signs of | | | inflammation, swelling, | | | warmth, tenderness, & | | | redness. | | | | | | - Assess muscle strength. | | +-----------------------------------+-----------------------------------+ | **Muscle strength** | **Grading Muscle Strength** | | | | | General | - **0** - no contractility 0% | | | | | - Allow for variables: age, | - **1** - slight contractility, | | sex, muscular training | no movement (trace) 10% | | | | | - Dominant side usually | - **2** - Full ROM w/ gravity | | slightly stronger | eliminated (poor) 25% | | | | | - Active resistance testing | - **3** - Full ROM w/ gravity | | | (fair) 50% | | - Paresis, paralysis, or | | | plegia? | - **4** - Full ROM against | | | gravity some resistance | | - Hemiparesis, hemiplegia, | (good) 75% | | paraplegia, quadriplegia | | | | - **5** - Full ROM against | | How to test | gravity full resistance | | | (normal) 100% | | - Test strength of prime mover | | | muscle groups for each joint | | | | | | | | | | | | - Ask patient to flex muscle | | | you indicate, then to resist | | | when you apply opposing force | | | against flexion | | | | | | - **Compare muscle strength | | | bilaterally** | | +-----------------------------------+-----------------------------------+ ### ### Examination of the Joints +-----------------------------------+-----------------------------------+ | Inspection | **Joint Movements\*\*\*** | | | | | - Inspect joint symmetry, | - **Flexion**: bending limb at | | alignment, & any bony | a joint | | deformities. | | | | - **Extension**: straightening | | - Inspect and palpate | limb at a joint | | surrounding tissues for skin | | | changes, nodules, muscles | - **Abduction**: moving a limb | | atrophy, & crepitus. | away from midline of body | | | | | Palpation | - **Adduction**: moving a limb | | | toward midline of | | - Palpate all bones, joints, | body | | and surrounding muscles | | | noting any **heat, | - **Pronation**: turning | | tenderness, swelling, | forearm so that palm is down | | masses** | | | | - **Supination**: turning | | - **Note muscle tone** | forearm so that palm is up | | | | | - Palpate inflamed joints last | - **Circumduction**: moving arm | | | in a circle around shoulder | | Range of Motion | | | | - **Inversion**: moving sole of | | - **Active ROM** for each major | foot inward at ankle | | joint and its related muscle | | | groups | - **Eversion**: moving sole of | | | foot outward at ankle | | - **Passive ROM** performed if | | | limitation with active ROM; | - **Rotation**: moving head | | [do not] force | around a central axis | | joint if pain, spasm or | | | resistance | - **Protraction**: moving a | | | body part forward and | | - Pain, limitation of motion, | parallel to the ground | | spastic movement, joint | | | instability, deformity, and | - **Retraction**: moving a body | | contracture indicate problem | part backward and parallel to | | with joint, muscle group, or | the ground | | nerve supply | | | | - **Elevation**: raising a body | | - May use goniometer to measure | part | | joint angle when ROM is | | | increased or limited | - **Depression**: lowering a | | | body part | +-----------------------------------+-----------------------------------+ Specific Joints & Muscles ------------------------- +-----------------------------------+-----------------------------------+ | **Temporomandibular Joint (TMJ)** | **Shoulders** | | | | | - Inspect & Palpate | ROM (cup one hand over shoulder) | | | | | - ROM | - **Forward** **Flexion:** | | | Raise both arms forward & | | - Open & close mouth (space | straight up over head | | of 3-6cm) | (180^o^) | | | | | - Laterally move lower jaw | - **Hyperextension:** Extend & | | to each side (1-2cm) | stretch both arms behind back | | | (50^o^) | | - Protract & retract chin | | | | - **Abduction:** Lift both arms | | - Muscle Strength | laterally & straight up over | | | head (180^o^) | | - Palpate muscles as | | | | - **Adduction:** Swing each arm | | - patient clenches teeth | across front of body (50^o^) | | | | | | - **Internal** **rotation:** | | | Place both arms behind hips, | | | elbows out (90^o^) | | | | | | - **External** **rotation:** | | | Place both arms behind head, | | | elbows out (90^o^) | +-----------------------------------+-----------------------------------+ | **Elbow** |  | | | | | - Inspect & Palpate | | | | | | - ROM | | | | | | - Bend & Straighten elbow | | | (flexion 160^o^; | | | extension 180^o^) | | | | | | - Flex elbow at right | | | angle; rotate hand from | | | palm side down to palm | | | side up (pronation 90^o^; | | | supination 90^o^) | | | | | | - **[Muscle | | | Strength]** | | | | | | - **[Patient to flex & | | | extend elbow against | | | resistance]** | | +-----------------------------------+-----------------------------------+ | **Wrist & | **Wrist & Hand Special | | Hand** | Test** | | | | | ROM | **Phalen's Test:** | | | | | - Bend hand up & down at wrist | - acute flexion of wrist for 60 | | (**flexion** 90^o^; | seconds at 90^o^. | | **hyperextension** 70^o^) | | | | - **Positive for Carpal | | - With palm side down, turn | Tunnel** | | hand to right and left | | | (**radial** motion 20^o^; | - Syndrome if numbness and | | **ulnar** motion 55^o^) | burning | | | | | - Bend fingers up & down at | **Tinel's Sign:** | | metacarpophalangeal joints | | | (**flexion** 90^o^; | - direct percussion of the | | **hyperextension3 0^o^**) | location of the median nerve | | | at wrist. | | - Touch thumb to each fingertip | | | & base of little finger | - Positive for Carpal Tunnel | | | Syndrome if numbness and | | - Spread finger apart, then | burning. | | touch them together | | | | | |  | | +-----------------------------------+-----------------------------------+ **The Spine** - Inspection: - Begin by observing the patient's posture: position of neck & trunk when entering the room. - Assess the patient for erect position of head, coordinated neck movement and ease of gait. - If possible, assess patient in standing position, with feet together & arms hanging at the sides. - Head should be midline in the same plane as the sacrum, the shoulders and pelvis should be level. - Lordosis, Kyphosis, Scoliosis - Bend forward at waist; touch toes; mark spinous processes with pen; check alignment - Assess posture - Note the body and head position - Check alignment and symmetry of shoulders, - Iliac crests, scapula- inspect front, back, and side. - Assess the spinal curvature - Have pt stand upright with feet together. Note the position of the knees. - ROM - **Flexion:** Bend forward at waist & touch toes (75-90^o^) - **Hyperextension:** Bend backwards at waist (30^o^) - **Lateral bending:** Bend sideways at waist (35^o^) - **Rotation**: Twist shoulders to one side, then the other (30^o^) - Palpation: - Palpate the spinous processes of each vertebra with your thumb. - Palpate over the acroiliac joint and paravertebral muscles +-----------------------------------+-----------------------------------+ | **Cervical Spine** |  | | | | | - Inspect & Palpate | | | | | | - ROM | | | | | | - **Flexion:** Touch chin | | | to chest (45^o^) | | | | | | - **Extension:** Lift chin | | | toward ceiling (55^o^) | | | | | | - **Lateral bending:** | | | Touch each ear toward | | | corresponding shoulder | | | (40^o^) | | | | | | - **Rotation**: Turn chin | | | toward each shoulder | | | (70^o^) | | | | | | - Muscle Strength | | | | | | - Repeat motions while | | | applying opposing force | | | | | | - **Cervical Spine** | | | | | | - Extension & Flexion | | | | | | - Lateral Bending | | | | | | - Rotation | | +-----------------------------------+-----------------------------------+ | **Thoracic and Lumbar Spine** | **Abnormalities** | | | | | - ROM: | +---------+---------+---------+ | | | | **Kypho | **Lordo | **Scoli | | | - Bend forward touch toes → | | sis | sis | osis | | | forward flexion | | (Hunch | (Sway | (spinal | | | | | Back)** | Back)** | curvatu | | | - Right lateral bending & | | | | re)** | | | rotation | |  | | e19.png | | ia/imag | | | | | ) | | e21.png | | | | | | | ) | | | | +---------+---------+---------+ | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Hip** | **Gait** | | | | | - Begin inspection of hip by |  | | observing the patient's gait | | | on entering the room. | | | | | | - Observe the two phases of | | | gait: stance and swing | | | | | | - Hip: Observe gait for width | | | of the base | | | | | | - ROM | | | | | | - **Flexion:** Supine, | | | raise leg with knee | | | extended (90^o^) | | | | | | - **Hyperflexion:** Supine, | | | raise one knee to chest | | | (120^o^) | | | | | | - **Abduction** 40-45^o^; | | | **Adduction** 20-30^o^ | | | | | | - Supine, swing leg | | | laterally & medially | | | with knee straight | | | while stabilizing | | | pelvis | | | | | | - **internal** **rotation** | | | | | | - Supine, flex knee & | | | rotate leg inward | | | toward other leg | | | (40^o^) | | | | | | - **external rotation** | | | | | | - Supine, place lateral | | | aspect of foot on | | | knee of other leg; | | | move flexed knee | | | toward table (45^o^) | | | | | | - **Hyperextension:** | | | Standing or prone, swing | | | straightened leg behind | | | body (30^o^) | | +-----------------------------------+-----------------------------------+ | **[Knees]** | | | | | | - Inspect & Palpate | | | | | | - ROM | | | | | | - **Flexion:** Bend each | | | knee (130-150^o^) | | | | | | - **Hypertextension | | | (Straight line)**: Extend | | | each knee (0-15^o^) | | | | | | - Muscle Strength | | | | | | - maintains flexion and | | | extension while applying | | | opposing force | | +-----------------------------------+-----------------------------------+ | **Ankles & Feet** | | | | | | - Inspect & Palpate | | | | | | - ROM | | | | | | - **Dorsiflexion:** Point | | | toes toward ceiling | | | (20^o^) | | | | | | - **Plantar flexion:** | | | Point toes toward floor | | | (45^o^) | | | | | | - **Inversion** 30^o^; | | | **Eversion** 20^o^) | | | | | | - Turn soles of feet in | | | then out | | | | | | - **Abduction** 10^o^; | | | **Adduction** 20^o^ | | | | | | - Rotate ankle, turn | | | foot away from & then | | | toward other foot | | | | | | - Flex & straighten toes | | | | | | - **[Muscle | | | Strength]** | | | | | | - Patient maintains | | | dorsiflexion & plantar | | | flexion while applying | | | opposing force | | | | | | - Documentation | | | | | | - Normal spinal curvature, | | | joints and muscles | | | symmetrical, no deformity | | | noted, | | | | | | - No complaints (no c/o) | | | pain, Full range of | | | motion (ROM) in upper and | | | lower extremities, muscle | | | strength + 5. no crepitus | | | noted. | | +-----------------------------------+-----------------------------------+ Older Adult ----------- Characteristics - Decreased height secondary to shortening of the vertebral column - Subcutaneous fat is redistributed in the abdomen and hips - Loss of muscle mass - Dont absorb calcium properly \*\*\* need resistance and weight training\*\*\* **Assistive Devices** -- walker, cane - Does the patient use one at home? - Is it easily available in the hospital or should the family bring it in? - Does the patient need physical therapy? - Is the device within the patient's reach? **Arthritis**  - proximal - bouchard nodes - Distal - herberden nodes **Health Promotion** - Nutrition, exercise, and weight - Proper calcium intake → prevent osteoarthritis - Increase bone mass - Reduce excess mechanical wear and tear - Exercise - Physical Activity Guidelines for Americans - At least 2 hours and 30 minutes/week of moderate-intensity, or 1 hour and 15 minutes/week of vigorous-intensity, aerobic physical activity or an equivalent combination - Moderate- or high-intensity muscle-strengthening activity that involves all major muscle groups on 2 or more days a week - Low back pain prevention - One of most vulnerable parts of skeleton - Most patients with acute LBP better in 6 weeks - Diet to maintain healthy weight - Exercises to strengthen lower back - Maintaining good posture and avoiding heavy lifting - Preventing falls - Leading cause of nonfatal injuries - Most common cause of traumatic brain injury - **95% of hip fractures due to falls** - Life expectancy after breaking hip is \1mm indicates pathology  **Vital Signs** - Changes in vital signs occur late. - Measure temperature, pulse, respiration, and blood pressure as often as condition warrants. **[Cerebellar Function: ]** +-----------------------------------+-----------------------------------+ | **Balance Tests** | **Rapid Alt Movements For | | | Assessing Coordination** | | - **Gait**: observe walk 10- 20 | | | feet, turns, returns to | - Client pats his knees with | | starting point. | palms of the hands followed | | | by backs of the hands at an | | - **Normal**: | ever increasing rate. | | | | | - person moves with sense | - Client touches each finger of | | of freedom; gait smooth, | one hand to the thumb of the | | rhythmic, and effortless | same hand as rapidly as | | | possible. | | - opposing arm swing is | | | coordinated | *Remember these from | | | Musculoskeletal Assessment??* | | - turns are smooth. | | | | | | - Step length about 15 | | | inches from heel to heel. | | | | | | - **Tandem Walking**: | | | heel-to-toe fashion. | | | | | | - Normal: person can walk | | | straight and stay balanced. | | | | | | - Romberg Test | | | | | | - Instruct patient to stand | | | with the feet together, | | | first with the eyes open | | | and then with the eyes | | | closed. | | | | | | - Slight swaying is normal. | | | | | | - **Stand close enough to | | | the client to prevent | | | falling.** | | | | | | - **Normal** :client is | | | able to do this for about | | | 20 seconds with the eyes | | | closed. | | +-----------------------------------+-----------------------------------+ | **Coordination & Skilled |  | | Movements** | | | | | | - **Finger to nose movements:** | | | | | | - touches his nose with | | | alternating index fingers | | | first with eyes open and | | | then closed.**(SELF)** | | | | | | - **Finger-nose-finger:** | | | | | | - With eyes open, touches | | | his nose and then your | | | finger. Increase speed as | | | you move your finger. | | | Test each hand | | | separately. **(HCP)** | | | | | | - **Heel to shin:** | | | | | | - ask client to run heel of | | | each foot down opposite | | | shin | | | | | | - **Finger to finger:** | | | | | | - **T**ouches fingers to | | | alternating fingers | | +-----------------------------------+-----------------------------------+ ***[Cranial Nerves]*** General - Enter and exit brain rather than spinal cord - CN I and II extend from cerebrum; cranial nerves III to XII extend from lower diencephalon and brain stem - 12 pairs of cranial nerves supply primarily head and neck, except the vagus nerve, which travels to heart, respiratory muscles, stomach, and gallbladder **Nerves:** +-----------------------------------+-----------------------------------+ | - **CNI**: Olfactory Nerve → in | - **CN VII:** Facial Nerve → | | nose; sense of smell | face, facial movements & | | | expressions | | - **CNII**: Optic Nerve → eyes; | | | central & peripheral vision | - **CN VIII**: Acoustic Nerve → | | | ears; hearing | | - **CNIII:** Oculomotor Nerve → | | | eyes; pupillary constriction | - **CN IX:** Glossopharyngeal | | | Nerve → tongue & throat | | - **CN IV:** Trochlear → moves | | | eyes downward | - **CN X:** Vagus Nerve → | | | tongue & throat | | - **CN V**: Trigeminal Nerve → | | | face; sensations & movement | - **CN XI:** Spinal Accessory → | | of face/jaw | neck & shoulder | | | | | - **CN VI**: Abducens Nerve → | - **CN XII:** Hypoglossal Nerve | | movements of eyes to the | → tongue | | sides | | +-----------------------------------+-----------------------------------+  **Motor Vs. Sensory Functions** +-----------------------------------+-----------------------------------+ | **Motor Nerves** | **Sensory Nerves** | | | | | - III - Oculomotor | - I -- Olfactory | | | | | - IV -- Trochlear | - II -- Optic | | | | | - VI -- Abducens | - VIII -- Acoustic | | | | | - XI -- Spinal Accessory | | | | | | - XII -- Hypoglossal | | +-----------------------------------+-----------------------------------+ | **Mixed** | | | | | | - I Olfactory (test smell) | | | | | | - II Optic: visual acuity, | | | visual fields & optic disc | | | | | | - III (oculomotor) | | | | | | - IV (trochlear) | | | | | | - VI (abducens) control | | | movement of eyeball, eyelid | | | and pupils. Checked together. | | +-----------------------------------+-----------------------------------+ Cranial Nerve Assessment - How do you assess the cranial nerves?? - Assess one at a time? - Cluster assessments together?? +-----------------------+-----------------------+-----------------------+ | **Cranial Nerve I = | **Cranial Nerves II, | **CN V - Trigeminal** | | SMELL** | III, IV, VI = | | | | VISION** | *sensory & motor* | | **Cranial Nerve I: | | | | Olfactory Nerve** | **Cranial nerve II: | *Responsible for | | | optic nerve** | sensation to the | | - Think Olfaction | | cornea.* | | (smell) & the | - Test visual | | | nose!! | acuity and visual | Sensation (Sensory): | | | fields by | 3 facial regions | | - Assess sense of | confrontation | | | smell | | - **Ophthalmic, | | | - Using | Maxillary & | | - Identify aromas | ophthalmoscope, | Mandibular** | | (vanilla, | examine ocular | | | lavender, | fundus to | - Sensory: Ask pt | | peppermint) | determine color, | to close eyes | | | size, and shape | | | - - Per | of optic disc | - touch each of **3 | | checklist, also | | areas lightly** | | assess nasal | **Cranial Nerves III, | (ophthalmic, | | patency | IV, and VI: | maxillary, & | | | oculomotor, | mandibular) → | | | trochlear, and | note pt ability | | | abducens nerves** | to detect | | | | stimulus. | | | - Palpebral | | | | fissures usually | - First with finger | | | equal in width | and then with | | | | toothpick | | | - Check pupils for | | | | size, regularity, | Motor: Temporalis & | | | equality, direct | Masseter muscles | | | and consensual | | | | light reaction, | - **Motor**: | | | and accommodation | Palpate TMJ → | | | | clench & grind | | | - Assess EOM by | | | | cardinal | - **Corneal | | | positions | Reflex:** tip | | | | (Sensory CN 5, | | | - (Nystagmus is | Motor CN 7) | | | back-and-forth | | | | oscillation of | - Blink when | | | eyes) | touch cornea | | | | w/cotton wisp | | | | | | | |  | +-----------------------+-----------------------+-----------------------+ | **CN VII (facial)** | **CN VIII | **CN IX | | | (Acoustic/Vestibuloco | (glossopharyngeal)** | | *motor to facial | chlear)** | | | muscles & sensory to | | Motor function | | taste.* | *hearing & | | | | equilibrium* | - Depress tongue | | Motor function: | | with tongue | | | Sensory | blade, and note | | - Note mobility and | | pharyngeal | | facial symmetry | - Test hearing | movement as | | as person | acuity by ability | person says | | responds to | to hear normal | "ahhh" or yawns; | | requests to | conversation and | uvula and soft | | smile, frown, | by whispered | palate should | | close eyes | voice test | rise in midline, | | tightly (against | | and tonsillar | | your attempt to | - Whisper Test: | pillars should | | open them), lift | Remember from Ear | move medially | | eyebrows, show | Assessment? | | | teeth | | - Touch posterior | | | - (Sometimes | pharyngeal wall | | - Facial | Romberg test may | with tongue | | Expressions: puff | be used to check | blade, and note | | cheeks (press | balance/equilibri | gag reflex; voice | | cheeks & see that | um) | should sound | | air escapes | | smooth, not | | equally from both | | strained | | sides) | | | | | | Sensory function | | A collage of a person | | | | smiling Description | | - Cranial nerve IX | | automatically | | does mediate | | generated | | taste on | | | | posterior one | | Sensory function: | | third of tongue, | | (not tested | | but technically | | routinely) | | too difficult to | | | | test | | - ONLY when suspect | | | | facial n. injury | | | | | | | | - Indicated then.. | | | | test sense of | | | | taste by applying | | | | cotton applicator | | | | covered with | | | | solution of | | | | sugar, salt, or | | | | lemon juice to | | | | tongue and ask | | | | person to | | | | identify taste | | | +-----------------------+-----------------------+-----------------------+ | **CN X (vagus)** | **Cranial Nerve XI - | **CN XII - | | | spinal accessory n.** | Hypoglossal N.** | | *Concerned with taste | | | | and sensation of the | *Motor strength of | *tongue movement* | | pharynx. Controls | SCM & trapezius m.* | | | swallowing, gag, and | | - Inspect tongue; | | salivating* | - Examine SCM and | no wasting or | | | trapezius muscles | tremors should be | | | for equal size | present | | | | | | | - Check equal | - Note forward | | | strength by | thrust in midline | | | asking person to | as person | | | rotate head | protrudes tongue | | | against | | | | resistance | - Ask person to say | | | applied to side | "light, tight, | | | of chin | dynamite," and | | | | note that lingual | | | - Ask person to | speech (sounds of | | | shrug shoulders | letters l, t, | | | against | d, n) is clear | | | resistance | and distinct | | | | | | | - movements should | | | | feel equally | | | | strong on both | | | | sides | | +-----------------------+-----------------------+-----------------------+ **Spinothalamic Tract ⇒ Sensory Function** - Apply stimuli to test major peripheral nerves. - Minimal \# of test sites includes areas on the forehead, cheek, hand, and foot. - In the screening exam, assume the nerve to be intact if sensation is normal at its most distal area. - When there is evidence of dysfunction, localize the site of the dysfunction and map the boundaries. Sketch the region involved and describe the sensory change. - Client closes his eyes. +-----------------------------------+-----------------------------------+ | **Sensation Assessment:** | | +-----------------------------------+-----------------------------------+ | **Touch, Temperature, & Pain** | **Discriminatory Sensations** | | | | | - **Light Touch Sensation:** | - **Tactile discrimination:** | | | Interpretation by the | | - use a wisp of cotton. | cerebral cortex. These | | Compare each side of the | assessments are tested with | | body | **Eyes Closed** | | | | | - **Pain and Temperature:** | - **Stereognosis**: | | | recognize objects by | | - Screening exam doesn't | touching and manipulating | | include temperature | them. | | assessment unless pain | | | sensation is abnormal. | - **Graphesthesia**: | | Compare side to side. | identify letters or | | | numbers written on each | | **Vibration Sensation Assessment | palm with a blunt point. | | (Posterior Column)** | | | | - **Two point discrimination:** | | - **Vibration**: Normally, | | | clients can perceive | - Ability to sense whether | | vibration as a buzzing or | one or two areas of the | | tingling sensation when a | skin are being stimulated | | bony prominence (wrist, | by pressure. | | elbow, ankle) touches base of | | | a vibrating tuning fork. | - To test this, apply | | | disposable pins or a | | - Client says "yes" or | paperclip bent into a "u" | | 'now" when first feeling | shape to the skin | | the vibrations and when | simultaneously. | | the vibrations stop. | | | | - Ask if client feels one | | - Compare side to side and | or two pinpricks. | | proximal to distal. | | | (Normal in older clients | - Open Paper Clip in "U' | | to have diminished | Shape | | vibratory sense.) | | | | - **Point Localization & | | **Sensation Assessment for Joint | Extinction** | | Position Sense (Proprioception or | | | Kinesthetic)** | - Point Localization : | | | | | - **Position** **sense** | - pt close eyes while | | (kinesthetic sensation): | you touch an area on | | perception of the position | body (upper or lower | | and motion of limbs and body | extremities) | | parts. | | | | - Have pt point to | | - With client's eyes closed | where you touch them | | and joint in a neutral | | | position, place your | - Test both sides, | | fingers on each side of | upper and lower | | the client's digit | extremities | | (finger or toe) and | | | slightly move the | - Sensory Extinction : | | position of the digit. | | | | - Simultaneously touch | | - Ask the client to | patient in an area on | | describe how the position | both sides of the | | of the finger changes. | body | | | | |  | were touched. | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | ***[Reflexes]*** | | | | | | - Use a reflex hammer to tap a | | | tendon. Record symmetry | | | comparing one side to the | | | other. | | | | | | - Use a stick figure | | | representation to document | | | the reflex findings. | | | | | | - **Reinforcement** is done to | | | enhance a reflex. | | | | | | - Person performs an | | | isometric exercise in a | | | muscle group somewhat | | | away from the one being | | | tested. | | +-----------------------------------+-----------------------------------+ | **[Reinforcement of | **[Corneal Reflex]** | | Reflex]** | | | | - Corneal reflex: | | - Deep Tendon Reflexes (DTR): | | | | - omit test, unless person | | - Biceps and Triceps | has abnormal facial | | Reflexes | sensation or | | | abnormalities of facial | | - Brachioradialis Reflex | movement | | | | | - Patellar/Quadriceps | - Remove any contact lenses; | | Reflex | with person looking forward, | | | bring wisp of cotton in from | | - Achilles Reflex | side (to minimize defensive | | | blinking) and lightly touch | | - Grading Reflexes | cornea, not conjunctiva | | | | | - 2+ = normal | - Normally person will | | | blink bilaterally | | - Plantar Superficial Reflexes | | | | - Corneal reflex may be | | - Reactions elicited by | decreased or absent in | | stroking the skin or | those who have worn | | muscle. | contact lenses | | | | | - Plantar reflex (L4, L5, | - procedure tests sensory | | S1, S2) elicited by | afferent in cranial nerve V | | firmly stroking the | and motor efferent in CNVII | | lateral surface of the | (muscles that close | | sole of the foot | eye) | | | | | - **Normal**: plantar | | | flexion of the toes | | | | | | - **Abnormal: + Babinski**: | | | extension of the great | | | toe and fanning of the | | | other toes | | | | | | - Before child can | | | walk, fanning and | | | extension of toes are | | | a normal finding. | | +-----------------------------------+-----------------------------------+ ***[Health Promotion]*** +-----------------------------------+-----------------------------------+ | **Preventing stroke and transient | **Stroke/Brain Attack** | | ischemic attack (TIA)** | | | | - Lobes of the Brain | | - Stroke | | | | - Frontal: personality, | | - Fifth leading cause of | behavior, emotions, & | | death | intellectual functions | | | | | - Leading of long-term | - Broca's Area: motor | | disability | speech → expressive | | | aphasia. | | - Symptoms and signs depend | | | on vascular territory | - Parietal: sensation | | affected in brain. | | | | - Occipital: visual receptor | | - Most common: middle | center | | cerebral artery | | | | - Temporal: auditory reception | | - Stroke RF: primary prevention | center | | | | | - HTN | - Wernicke's Area: language | | | comprehension → receptive | | - Smoking | aphasia. | | | | | - Hyperlipidemia | RF | | | | | - Diabetes | - Hypertension | | | | | - Weight | - Diabetes mellitus | | | | | - Diet and nutrition | - Cocaine use | | | | | - Physical Activity | - Cigarette smoking | | | | | - Alcohol use | - Hyperlipidemia | | | | | - Disease-Specific RF | - Chronic atrial fibrillation & | | | flutter | | - A fib | | | | - Sickle cell disease | | - Carotid artery disease | | | | - IV drug abuse | | - Obstructive sleep apnea | | | | - Alcohol abuse | | | | | | - Obesity | | | | | | - Oral contraceptive use; | | | especially in women over age | | | 35 who smoke and have | | | hypertension | +-----------------------------------+-----------------------------------+ Mental Status ============= +-----------------------------------+-----------------------------------+ | **[Symptoms and | **[The Health | | Behavior:]** | History:]** | | | | | - Understanding Patient | Common or Concerning Sx→ related | | Symptoms: | to mental status include: | | | | | - What do they mean? | - Changes in attention, mood, | | | or speech | | - Psychological? Relating | | | to mood or anxiety | | | | | | - Physical? Relating to | - Changes in insight, | | body sensation (somatic) | orientation, or memory | | | | | - 30% symptoms are | - Delirium or dementia | | medically unexplained | | | | Overview of Mental Status | | - Functional syndromes | | | | - Begin to assessment mental | | - Unexplained Symptoms | status when you first meet | | | your patient | | - Unexplained physical or | | | somatic sx | - Some areas to focus on | | | include: | | - Patients with depression | | | | - Level of alertness and | | - 2/3 present w/ | orientation | | somatic complaints | | | | - Mood | | - 1/2 present w/ | | | multiple unexplained | - Attention | | somatic complaints | | | | - Memory | | - Functional syndrome: | | | frequently co-occur and | - Insight and judgment | | share key sx and | | | selective objective | - Recurring or unusual | | abnormalities | thoughts or perceptions | | | | | - When to Screen Patients' | - Attention, Mood, Speech, | | Mental Health | Insight, Orientation, & | | | Memory | | - Indicators for Selective | | | Mental Health Screening | - As you are completing the | | | health history pick up on: | | - Medically unexplained | | | physical symptoms | - Level of consciousness | | | | | - Multiple physical or | - General appearance | | somatic symptoms or | | | "high symptom count" | - Mood (depression or | | | mania) | | - High severity of | | | presenting somatic | - Ability to: | | symptom | | | | - Pay attention | | - Chronic pain | | | | - Remember | | - Symptoms for more | | | than 6 weeks | - Understand | | | | | - Rating as a | - Speak | | "difficult encounter" | | | | - Neurocognitive Disorders | | - Recent stress | | | | - Delirium | | - Low self-rating of | | | health | - Presents in varying | | | states | | - High use of health | | | care services | - Related to metabolic | | | or structural brain | | - Substance abuse | alteration | | | | | - High Yield Screening | - Considered separate | | | classification of | | - Depression | neurocognitive | | | disorders | | - Over the past 2 | | | weeks, have you felt | - Major Neurocognitive | | down, depressed, or | Disorder | | hopeless? | | | | - Dementia (document in | | - Over the past 2 | parenthesis due to | | weeks, have you felt | widespread clinical | | little interest or | usage) | | pleasure in doing | | | things (anhedonia)? | - Mild Neurocognitive | | | Disorder | | - Anxiety | | | | - Traumatic brain | | - Anxiety disorders | injury or HIV | | include: generalized | infection--related | | anxiety disorder, | impairment in younger | | social phobia, panic | individuals | | disorder, | | | posttraumatic stress | | | disorder, and acute | | | stress disorder. | | | | | | - Over past 2 weeks: | | | feel nervous, | | | anxious, on edge, | | | unable to stop | | | worrying | | | | | | - Over past 4 weeks, | | | have you had an | | | anxiety attack, | | | suddenly feeling fear | | | or panic? | | | | | | - CAGE Questions | | +-----------------------------------+-----------------------------------+ ***[The Physical Examination]*** **Important Areas of the Mental Status Examination** - Appearance and behavior - Speech and language - Mood - Thoughts and perceptions - Cognition, including memory, orientation, attention, and higher cognitive functions such as information and vocabulary, calculations, abstract thinking, and constructional ability **Appearance & Behavior** +-----------------------------------+-----------------------------------+ | - Level of consciousness | - Mood | | | | | - Awake and alert? | - Sadness and deep | | | melancholy | | - Responding appropriately | | | and reasonably quickly? | - Contentment, joy, | | | euphoria, elation | | - Lose track of topic? | | | | - Anger and rage | | - Fall silent or even | | | asleep? | - Anxiety and worry | | | | | - Posture and motor behavior | - Detachment and | | | indifference | | - Patient lie in bed or | | | prefer to walk around? | - Thoughts and Perceptions | | | | | - Body posture? | - Thought content | | | | | - Able to relax? | - Follow appropriate leads | | | as they occur | | - Pace, range, and | | | character of movements? | - Be tactful and accepting | | | | | - Dress, Grooming, and Personal | - Perceptions | | Hygiene | | | | - Inquire about false | | - Clothing clean and | perceptions in manner | | appropriate for age and | similar to that used for | | weather? | thought content | | | | | - Hair, nails, teeth, skin, | - "When you heard the | | and beard? | voice speaking to | | | you, what did it | | - Groomed? | say?" | | | | | - Grooming and hygiene | - "Sometimes after | | comparable to other | major surgery like | | people? | this, people hear | | | peculiar or | | - Compare one side of body | frightening things. | | to other? | Have you experienced | | | anything like that?" | | - Facial expression | | | | - Insight and Judgment | | - At rest? | | | | - Usually best assessed | | - During interaction with | during interview | | others? | | | | - Insight | | - Variations with topics? | | | | - Note whether patient | | - Appropriate? | is aware that a | | | particular mood, | | - Relatively immobile? | thought, or | | | perception is | | - Manner, Affect, and | abnormal or part of | | Relationship to People and | an illness | | Things | | | | - Judgment | | - External expression of | | | inner emotional state? | - Note patient's | | | responses to family | | - Vary appropriately? | situations | | | | | - Labile, blunted, or flat? | - Note whether decisions | | | and actions are based on | | - Inappropriate or extreme | reality or on impulse, | | at times? | wish fulfillment, or | | | disordered thought | | - Openness, | content | | approachability, and | | | reactions to others and | - Cognitive Functions | | surroundings? | | | | - Orientation | | - Hear or see things that | | | you don't? | - Can be determined by | | | interview | | - Assess Speech & Language | | | | - Ask naturally for | | - Quantity | specific dates, | | | address, phone | | - Talkative or silent? | number, etc. | | | | | - Spontaneous or only | - Person | | responsive to direct | | | questions? | - Place | | | | | - Rate | - Time | | | | | - Fast or slow? | - Situation | | | | | - Loudness? | - Attention & Memory | | | | | - Loud or soft? | - Attention | | | | | - Articulation of words | - Digit span | | | | | - Clearly and | - Serial 7s | | distinctly? | | | | - Spelling Backward | | - Nasal quality to | | | speech? | - Need to consider | | | possibility of | | | limited education | | | | | | - Remote memory | | | | | | - Birthdays, | | | anniversaries, SSN, | | | names of schools | | | attended, jobs held, | | | past historical | | | events | | | | | | - Recent memory | | | | | | - Events of the day, | | | weather, today's | | | appointment time, | | | laboratory tests | | | taken during the day | +-----------------------------------+-----------------------------------+ **Mini-Mental Status Exam (MMSE)** - Recording Your Findings ⇒ Recording behavior and mental status - Mental status - Grooming - Speech - Thought process - Orientation - Memory ***[Health Promotion]*** +-----------------------+-----------------------+-----------------------+ | Depression (Major | Suicide | Substance Abuse | | depression) | | | | | - Preventing | - Including Alcohol | | - Common mental | suicide is | and Prescription | | illness | national public | Drugs | | | health initiative | | | - Frequently | | - Interactions and | | coexists with | - Tenth leading | comorbidity of | | other mental | cause of death in | alcohol and | | disorders | the United States | substance abuse | | | | with mental | | - Frequently | - Clues to pending | disorders and | | accompanies other | suicide are | suicide are both | | serious illnesses | variable and | extensive and | | | subtle | profound | | - Primary care | | | | providers often | Watch for risk | - Alcohol, tobacco, | | miss early signs | factors | and illicit drugs | | | | account for more | | - Screening in | - Depression, other | illness, deaths, | | clinical settings | mental disorders, | and disabilities | | to provide | substance | than any other | | accurate | abusers, prior | preventable | | diagnosis, | attempts, | condition | | treatment, and | delusional or | | | follow-up | psychotic |  | | | incarceration | | +-----------------------+-----------------------+-----------------------+ Older Adults ============ Objective - Use the techniques that best facilitate the health history and physical examination of the older adult. - Identify focus areas during the health history specific to the older adult. - Recognize normal physiologic changes in the older adult. - Use screening tools in the assessment of older adults. - Perform a health history on an older adult. - Perform a physical examination on an older adult. - Document the older adult assessment findings. - Address area of health promotion and counseling specific to the older adult. Assessing Older Adults - In United States, there 43 million older adults, expected to reach 80 million by 2040. - Life span: 81 years for women, 76 years for men - Over 85 years: projected to double from 6 million to over 14 million in 2040 - 95% of Americans older than age 65 live in the community; 5% reside in institutional facilities - Over 85 years: only 10% live in institutional facilities Physiologic Changes with Aging - Vital signs - Blood pressure - Systolic hypertension with widened pulse pressure - Diastolic stops rising at approximately the sixth decade - Postural (orthostatic) hypotension - Heart rate and rhythm - Abnormal heart rhythms: atrial or ventricular ectopy Respiratory rate - Unchanged - Temperature - Changes in regulation lead to susceptibility to hypothermia - Skin, Nails, and Hair - Skin: wrinkles, loses turgor, appears thin, age spots, fragile, loose - Nails: lose luster, yellow, thicken - Hair: scalp hair loses its pigment, loss in various areas; over 55 in women, coarse facial hair appears - Evaluate all individuals according to their ethnicity - Head and neck - Eyes and Visual Acuity - Loss of fat around face - Dry eyes - Pupils become smaller - Visual acuity diminishes (presbyopia) - Increase risk for cataracts, glaucoma, macular degeneration - Ears - Hearing acuity diminishes (presbycusis) - Mouth, Teeth, and Lymph Nodes - Diminished salivary secretions - Decreased sense of taste - Decreased olfaction - Teeth wear down; periodontal disease - Thorax and lungs - Chest wall becomes stiffer and harder to move - Respiratory muscles weaken - Lungs lose some elastic recoil - Lung mass declines - Cough becomes less effective - Kyphosis from osteoporotic vertebral collapse - Barrel chest - Cardiovascular system - Cardiac output - Myocardial contraction less responsive - Modest drop in resting heart rate - Significant drop in maximum HR during exercise - Diastolic dysfunction from decreased early diastolic filling - Increased myocardial stiffness - Risk of heart failure Extra heart sounds: S~3~ and S~4~ - Suggests decreased ventricular compliance and impaired ventricular filling - Cardiac murmurs - Systolic aortic murmur - Aortic sclerosis - Aortic stenosis - Mitral regurgitation - Physiologic Changes with Aging - Peripheral vascular system - Peripheral arteries tend to lengthen, become tortuous, feel harder and less resilient - Loss or arterial insufficiency is not typical - Important concern: possible abdominal aortic aneurysm; complaint of abdominal or back pain, especially male mokers with coronary disease - Abdomen - Fat tends to accumulate in lower abdomen near hips - Aging may blunt manifestations of acute abdominal pain - Pain may be less severe - Fever is less pronounced - Signs of peritoneal inflammation may be diminished or even absent - Female and Male Genitalia - Urinary Incontinence - Increases with age in both women and men - May be related to decreased innervation and contractility of detrusor muscle, loss of bladder capacity, changes in rinary flow rate, ability to inhibit voiding - Injury to or weakening of supporting pelvic muscles in women - Benign prostatic hyperplasia (BPH)---androgen-dependent proliferation of prostate epithelial and stromal tissue - Musculoskeletal system - Significant loss of height - Most occurs in trunk as intervertebral discs become thinner - Vertebral bodies shorten or even collapse from osteoporosis - Skeletal muscles decrease in bulk and powe - Range of motion diminishes - Mental Status Assessment and Nervous System - Most older adults maintain their self-esteem and adapt well to changing capacities and circumstances - Mental Status - Complaints about memory issues - "Benign forgetfulness" - Slow motor responses - Diminished ability to perform complex tasks - Depression versus Dementia versus Delirium - Mental Status Assessment and Nervous System - Motor system changes are common - Move and react with less speed - Skeletal muscles decrease in bulk - Hands appear wasted - Arm and leg muscles show signs of atrophy - Benign essential tremor in head, jaw, lips, or hands - May be confused with parkinsonism (no rigidity) - Emotional Concerns - Death of loved ones - Diminution in income - Decreased physical capacities - Possible growing social isolation **The Health History: Approach to the Older Patient** - Address cultural dimensions of aging - Wide array of cultural differences based on different ethnic groups - Cultural differences affect: - Specific concerns of the elderly - Disparities in health outcomes - Cultural and socioeconomic attributes affect epidemiology of illness - Choices about healers and when to pursue symptoms - Elicit symptoms in the older adult - Patients may accidentally or purposefully underreport symptoms - Presentation of acute illnesses may be different - Common symptoms may mask a geriatric syndrome - Patients may have cognitive impairment 10-minute geriatric screener  Special Areas of Concern When Assessing Common or Concerning SymptomsA table with text on it Description automatically generated The Hospitalized Older Adult  Characteristics of Acute and Persistent PainA table of medical information Description automatically generated Assessing Alcohol and Tobacco Use - Smoking and alcohol - Advise patient to quit smoking - Estimated 4.5% to 14% older than 65 years have alcohol-related problems - Detection and treatment is low - Detection is important due to drug--alcohol interactions - 30% of older adult drinkers exacerbate chronic conditions Detecting alcohol use disorders in older adults: clinical clues  Physical Examination: Points to remember - Take advantage of opportunistic assessments. - May not be able to complete entire assessment in a single visit. - Maintain safety measures throughout assessment. - Vision and hearing - Important to help patient maintain optimal function - Key items in 10-Minute Geriatric Screener - Test vision objectively using vision chart - Ask about hearing loss may be adequate - More formal hearing test if indicated **[Health Promotion and Counseling: ]** **Exercise** - CDC Exercise Recommendations for Older Adults - 2-hour, 30-minute moderate-intensity aerobic activity/week and muscle-strengthening activities 2 or more ays/week that work all major muscle groups - OR - 1-hour, 15-minutes vigorous-intensity aerobic activity/week and muscle-strengthening activities 2 or more ays/week that work all major muscle groups - OR - Equivalent mix of moderate and vigorous exercise and muscle-strengthening exercises 2 days/week Immunizations - Influenza vaccine - Pneumonia vaccine (PPSV23, PCV13) - Herpes zoster vaccine - Tdap and Td - Consult CDC for latest guidelines - Health Promotion and Counseling **[USPSTF Screening Recommendations for Older Adults]** ------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------ Breast Cancer Women: every 2 years ages 50- Cervical Cancer None for women over 65 if normal Pap smears and not at high risk for cervical cancer Colorectal cancer Colonoscopy every 10 years; sigmoidoscopy every 5 years with FOBTs every 3 years or FOBT's every year age 50-75 years; no routine screening 76 to 85 years Prostate Cancer No PSA screening of all ages Lung Cancer Annual CT for ages 55-80 years with 30 pack/year history, currently smoke, or quit in past 15 years, stop after completing 15 years without smoking Skin Cancer None, evidence insufficient ------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------ Depression - Underdiagnosed, untreated, undertreated - Initial screening with 2 basic questions - Over the past 2 wks have you felt down, depressed, or hopeless? - Over the past 2 wks have you felt little interest or pleasure in doing things? - Follow up positive responses with Geriatric Depression Scale Elder Mistreatment and Abuse - Abuse, neglect, exploitation, abandonment - Many afraid to report; 80% to 90% are family members - Self-neglect is a growing national concern - No single instrument for rapid yet accurate assessment and diagnosis of this important problem - Assess for physical signs, behavior, refusal of caregiver to leave patient alone, use of restraints Advance Directives and Palliative Care - Expressed wishes about end-of-life decisions - Advance care planning - Provides information about patient's wishes - Identifying p