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Lecture Three: Initial Patient Assessment

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In this presentation student can find essential information about methods of patient's history taking, and basics of neurological examination

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Lecture Three: Initial Patient Assessment

  1. 1. Patient History Taking andPatient History Taking andPatient History Taking and Patient History Taking and  Neurological Examination for Neurological Examination for  PharmacistsPharmacists Anas Bahnassi PhD
  2. 2. Anas Bahnassi PhD CDM CDE 2
  3. 3. General History:General History: History taking and clinical examination  form the basis of all clinical assessments.  The history enables a short listThe history enables a short list  of differential diagnoses to be  gene rated. Evidence from  clinical examination can beclinical examination can be  used to refine this. 3Anas Bahnassi PhD CDM CDE
  4. 4. Steps of Steps of  History Taking:History Taking: f h lHistory of the presenting complaint Systemic inquirySystemic inquiry Past medical history Drug history Family and social history Psychiatric historyPsychiatric history Recording the history 4Anas Bahnassi PhD CDM CDE
  5. 5. History of the  presenting complain: You need to 1. Identify your patient. 2. Start with open questions: 1 h h d h l fYou need to  structure the  i i i 1. What happened over the last few  days? 2. When was the last time you felt  interview in a way  that allows you to  y well? 3. Listen during the first part of the  ti d l t ti t t lk extract the relevant  information, while  conversation and let your patient talk. 4. Form a differential diagnosis based on  the patient description., remaining relaxed  and polite p p 5. In the second part use closed end  questions to focus on specific points  and narrow your differential diagnosisand polite.  and narrow your differential diagnosis. Anas Bahnassi PhD CDM CDE 5
  6. 6. History of the  presenting complain: You need to 6. Duration and speed of onset of the  patient’s symptoms are particularly You need to  structure the  i i i p y p p y important. if f l l i l d f tinterview in a way  that allows you to  e.g. if a focal neurological defect  develops over the course of a few  minutes, this could be due to an acute  extract the relevant  information, while  vascular event; if it develops over a  number of days there may be  infection or demyelization while a, remaining relaxed  and polite infection or demyelization, while a  defect that develops over  months  could suggest an underlying tumor or  and polite.  subdural hemorrhage  Anas Bahnassi PhD CDM CDE 6
  7. 7. History of the  presenting complain: You need to 7. Avoid asking more than one question  at once.You need to  structure the  i i i 8. Use language that the patient will  understand and avoid medical  t i linterview in a way  that allows you to  terminology. 9. Ask if the patient has any worries or  concerns: extract the relevant  information, while  Fear and preconceptions often color  the interpretation of symptoms and, remaining relaxed  and polite the interpretation of symptoms and  are always important features of the  history and polite.  Anas Bahnassi PhD CDM CDE 7
  8. 8. Systemic inquiry:y q y A few further • Cardiovascular : chest pain,  palpitations, breathlessness,  orthopnoea oedemaA few further  screening questions  ffi i orthopnoea, oedema • Respiratory : breathlessness, cough,  sputum, hemoptysis, chest pain  are sufficient to  identify any areas  • GI: abdominal pain or swelling, bowel  habit and bleeding, vomiting,  • swallowing problems worthy of additional  focus: swallowing problems  • GU: dysuria, frequency, urgency,  hematuria • Neurological symptoms: headache,  weakness or altered sensation, fits,  falls and funny turns, change vision,falls and funny turns, change vision,  hearing or speech.  • Systemic: anorexic. Anas Bahnassi PhD CDM CDE 8
  9. 9. Past Medical History:y Inquire about the Disease Informal Label A th COPD B hiti hInquire about the  following common  ill Asthma, COPD Bronchitis, emphysema Ischemic Heart Disease Angina Myocardial Infraction Heart Attack illnesses: Myocardial Infraction Heart Attack Cardiac failure Fluid on the lung Diabetes Mellitus Blood sugar Remember that  patients often g TB Surgery patients often  employ informal  Stroke, epilepsy Fits Hypertension Blood pressure labels: Hypercholesterolemia Venous thromboembolism Clots Anas Bahnassi PhD CDM CDE 9 Rheumatic fever Major childhood illness
  10. 10. Drug HistoryDrug History • A t d i l di th ti i f d i i t ti• Accurate doses, including the timing of administration, are  essential, especially for insulin regimes and patients taking warfarin,  along with details of the specific formulation taken. If th ti t i l t f di ti k if th h t• If the patient is on a lot of medications, ask if they have an up‐to‐ date repeat prescription with them.  • Make specific note of drug allergies.  • Ask what the patient means by ‘allergy’:  – Feeling sick or diarrhea is often mislabelled as such.  • In patients with lung disease, check if they are prescribed inhalersIn patients with lung disease, check if they are prescribed inhalers  and that they  know how to use them. Also ask if they are on long‐ term oxygen therapy (marker of disease severity).  • Check if the patient is on long‐term oral theophylline or phenytoin;Check if the patient is on long term oral theophylline or phenytoin;  if so, you will need to measure a drug level before prescribing any  additional IV treatment.  Anas Bahnassi PhD CDM CDE 10
  11. 11. Family and Social HistoryFamily and Social History • Social history is often an overlooked component  especially for older and disabled patients. I i b t diti ff ti f il b• Inquire about conditions affecting family members. • Document home circumstances: Li i l h i t t– Living alone, housing type, etc… • Ask if the patient has family nearby and if they see them.  • Determine the patient’s functional capacity and whether• Determine the patient’s functional capacity and whether  they are able to perform the activities of daily living  (ADLs), e.g. leaving the house, doing the shopping.(ADLs), e.g. leaving the house, doing the shopping.  Anas Bahnassi PhD CDM CDE 11
  12. 12. Family and Social HistoryFamily and Social History • Ask about quality of life (QoL). Remember that this should be  recorded as the patient describes it, not how you judge it. A k b t ti l d• Ask about recreational drug use.  • Document cigarette use by current and ex‐smokers in pack‐ years and alcohol consumption in units per weekyears and alcohol consumption in units per week. – One pack‐year equates to a pack of 20 cigarettes  per day for a year: someone who has smoked 10‐a‐ day for 50 years has a 25 pack‐year history.  – One small glass of wine or one 25 mL measure of  spirits is roughly equivalent to 1 unit; 1 pint of p g y q ; p ordinary strength lager, beer or cider roughly  equates to 2 units. Recommended safe limits of alcohol per week for Anas Bahnassi PhD CDM CDE 12 – Recommended safe limits of alcohol per week for  males and females are 21 and 28 units, respectively
  13. 13. Psychiatric HistoryPsychiatric History A d t il d hi t i ti l d t• A detailed history is essential and must  include the following: – Educational background, religion and occupation, as these mayEducational background, religion and occupation, as these may  influence interview technique and general approach. – Reason and source of referral (self‐presentation indicates  insight)insight).  – Inquire about the patient’s symptoms in their own words,  including their effect upon normal function (e.g. work, family,  relationships) date of onset rate of progression and anyrelationships), date of onset, rate of progression and any  precipitants identified by the patient. – Previous treatments, including drugs, surgery and others, e.g.  cognitive behavioral therapy electro‐convulsive therapycognitive behavioral therapy, electro‐convulsive therapy  – Suicidal ideation. Anas Bahnassi PhD CDM CDE 13
  14. 14. Personal HistoryPersonal History • P l hi t h ld i l d• Personal history should include: – Childhood problems including parental separation and any history of  abuse.  R l ti hi d it l hi t– Relationships and marital history.  – Work history, including current level of satisfaction at work and  reasons for leaving previous jobs. ill l ti iti d hi t f i l– illegal activities and any history of violence  – Premorbid personality, e.g. anxious, obsessive, solitary  – Cognitive assessment should be performed (cognitive dysfunction  t i th th f ti l th l )suggests organic rather than functional pathology)  – Abbreviated mental test (AMT) score or the mini‐mental state  examination (MMSE).  A t (d li i ) d h i (d ti ) iti i i t h ld– Acute (delirium) and chronic (dementia) cognitive impairment should  be distinguished by discussion with family members or social contacts.  Anas Bahnassi PhD CDM CDE 14
  15. 15. Abbreviated Mental Test Score Wh t i ? 1 if tWhat is your age? 1 if correct What is your date of birth? 1 if correct Wh t i it? 1 if tWhat year is it? 1 if exact year What time of day is it? 1 if correct to the next hour Wh t i thi l ? 1 if t ( f h it l hWhat is this place? 1 if correct (name of hospital or pharmacy  area) Recall a 3 line address 1 if totally recalledRecall a 3 line address 1 if totally recalled Who is the current Monarch? 1 if correct What year was world war 2? 1 if correctWhat year was world war 2? 1 if correct Count backward from 20 to 1 1 if correct with no mistakes Can you identify these two people? 1 if correct names or correct jobs (dependsCan you identify these two people? 1 if correct names or correct jobs (depends  if the patient knows the names or not) Anas Bahnassi PhD CDM CDE 15 Total score is recorded out of 10 A score <7 suggests cognitive dysfunction.
  16. 16. Mini Mental State Examination Test Question Max ScoreTest Question Max Score Time Day, date, month, season, year 5 Place Country, county, city, building, floor. 5y, y, y, g, Registration Name 3 objects: “bed, table, book,… ) 3 Attention and  C i Spell ‘world’ backwards or count out five serial 7s 5 Concentration Naming Name 2 objects 2 Recall Ask to recall the 3 objects registered earlier 3Recall Ask to recall the 3 objects registered earlier 3 Repeating Repeat ‘no ifs, ands or buts’: only correct if word perfect 1 3‐Stage task Instruct the patient to (1) take this paper in your right  3 hand, (2) fold it in half and (3) drop it on the floor Reading Write ‘close your eyes’; ask the patient to  read and obey 1 Writing Write a sentence: must be complete and grammatically  correct 1 Construction Draw interlocking pentagons 1 Anas Bahnassi PhD CDM CDE 16 Construction Draw interlocking pentagons 1 Total score recorded out of 30; <23 suggests cognitive impairment.
  17. 17. Recording the HistoryRecording the History Many hospitals now provide an admission pack, which includes a history taking  proforma for all new admissions. These documents often form part of a unified  case record (UCR) or integrated care path a (ICP) While these tools are sef lcase record (UCR) or integrated care pathway (ICP). While these tools are useful,  there is a danger that they encourage a highly protocolized, ‘tick‐box’ approach  to history taking.  Take time to work beyond the boxes and fully  explore what the patient is trying to tell you.  When recording the history of the presenting  complaint, include the main problem and mode of  f lreferral.  This should be followed by a short paragraph that covers the relevant additional  positive or negative points from the history with regard to this presenting Anas Bahnassi PhD CDM CDE 17 positive or negative points from the history with regard to this presenting  problem.
  18. 18. ExaminationExamination • Ensure that the patient’s need for privacy is met.Ensure that the patient s need for privacy is met. • Ask for permission to examine them and check if there is any area that is  sore to touch.  • Ensure that the patient is comfortable and in the correct body position• Ensure that the patient is comfortable and in the correct body position  for the system you aim to assess Supine Position Semi‐recumbent Position • Cardiovascular and respiratory : 45° semi‐recumbent  • Abdominal : lying supine  • Neurological : semi‐recumbent position in bed or sitting in chair, depending on  th ti l i ti f d Anas Bahnassi PhD CDM CDE 18 the particular examination performed. 
  19. 19. Begin with a general examination, then follow the principles of inspection,  palpation, percussion and auscultation as you work through the relevant body  systems. Note that when palpating, you should start with the least painful side first and  work slowly towards the site of worst pain. Neurological Assessment: Inspectionp Note any abnormality of resting limb position (contracture or palsy),  involuntary movements (seizure activity, tremor and chorea), muscle wasting,  fasciculation and gait. Cranial nerves Examine cranial nerves II–XII; Cranial nerve I (olfactory nerve) is not routinely assessed. Anas Bahnassi PhD CDM CDE 19
  20. 20. Tests Routinely Performed on Cranial Nerves Cranial nerve Tests routinely performed II (Optic) Acuity, pupillary reflexes (ipsi‐ and contralateral), visual fields III (Oculomotor) Considered together: ocular movements IV (Trochlear) VI (Abducent) V (Trigeminal) Ophthalmic (V 1 ), maxillary (V 2 ) and mandibular (V 3 ) sensory  branches; motor function (masseter muscle) rarely tested VII (Facial) Five sensory branches (raise eyebrows, close eyes tight, show( ) y ( y , y g , teeth, puff out cheeks and whistle); taste rarely tested. VIII (Vestibulocochlear) Rarely tested; hearing deficits best assessed by audiometry IX (Glossopharyngeal) Considered together: gag reflex (IX afferent, X efferent); movement of the soft palate (uvula) X (Vagus) XI (Accessory)  Shrug shoulders and resist: rotate head to one side against resistance to test the contralateral sternomastoid muscle Anas Bahnassi PhD CDM CDE 20 resistance to test the contralateral sternomastoid muscle XII (Hypoglossal) Ask patient to protrude tongue, look for wasting asymmetry and  fasciculation
  21. 21. Cranial Nerve II (and III) • Visual Field • Pupil assessments – SizeSize – Shape – Reaction to light – Accommodation • While we are there … – Look for Horner or bilateral ptosis (Mysathenia)
  22. 22. Cranial Nerve III, IV and VI • Assess eye movement on command • Ask for diplopia • Look for nystagmus Remember the “H”• Remember the H
  23. 23. Cranial Nerve V • Sensory component – Facial sensation in dermatomes of three trigeminal divisions – Testing of corneal reflex not expected • Motor component• Motor component – Jaw reflex – Masseter muscle
  24. 24. Cranial Nerve VII • Look for facial asymmetry • Test for muscle power
  25. 25. Cranial Nerve IX and X • Glossopharyngeal nerve: – Inspect mouth: “Aaaaaaaaaaaaaaaaaaaaah”p • uvula displacement • Asymmetrical rise of velum • Gag reflex – Sensory component: glossopharyngeal nerve – Motor component: vagal nerve
  26. 26. Cranial Nerve XI • Accessory nerve:
  27. 27. Cranial Nerve XII • Hypoglossal nerve: L k f d i ti f th t– Look for deviation of the tongue – Also look for fasciculations of the tongueg
  28. 28. Neurological Assessment: Motor examination For motor examination, assess tone, power and reflexes, starting proximally and moving distally; compare right with left. Give the patient clear instructions when examining power. It is important to distinguish between upper and lower motor neurone weakness. Tone : ‘normotonia’ varies; if hypertonia is genuine, check whether  l l d l k f h l dsymmetrical or generalized; look for cog‐wheeling or associated  clonus (hard clinical sign if sustained) Anas Bahnassi PhD CDM CDE 28
  29. 29. ToneTone  • Resistance to Passive Movement • Child should be relaxed (ie distract them withChild should be relaxed (ie distract them with  chat) *Note difference; hypotonia vs. joint flexiblity ff ; yp j f y • Clonus; ‘rhythmic series of involuntary muscle contraction  evoked by stretching the muscle’
  30. 30. ↑ Tone↑ Tone • Spasticity; rapid build‐up of • Rigidity;  sustained resistance resistance during first few degrees of passive passive movement movement,  then resistance lessens – Extrapyramidal / Basal  ganglia – Involves a single group  of muscles (agonist or  g g antagonist)
  31. 31. What is the difference between  spasticity and rigidity? S i i d i idi 2 f h i li i d h i i hSpasticity and rigidity are 2 types of hypertonic states elicited when examining the  tone of limbs. It is important to differentiate between them to arrive at a correct  diagnosis. S ti itSpasticity: Seen in pyramidal tract lesions Classically termed ‘Clasp knife spasticity’ – more tone during the initial part of  movement as in opening a pocket knifemovement – as in opening a pocket knife It is velocity dependant – should be elicited by fast movement of the muscle groups  involved Rigidity:Rigidity: Seen in extrapyramidal lesions – like parkinsonism Cog wheel rigidity – Tremor superimposed on hypertonia – resulting in  intermittent increase in tone during the movement – felt as jerksintermittent increase in tone during the movement  felt as jerks Lead pipe rigidity – Uniform increase in tone Velocity independent – does not vary with speed of movement of muscle groups  Anas Bahnassi PhD CDM CDE 31 y p y p g p involved
  32. 32. Tone • How to do it: – Passive rotation of wrist with supination and pronation at elbow joint with elbow supportedpronation at elbow joint with elbow supported • Look for:oo o – Hypertonic (upper motor neuron or extrapyramidal lesion) – Hypotonia C h l i idit– Cogwheel rigidity (Parkinson) – Myotonia (increased tone after movement)Myotonia (increased tone after movement)
  33. 33. Neurological Assessment: Motor examination For motor examination, assess tone, power and reflexes, starting proximally and moving distally; compare right with left. Give the patient clear instructions when examining power. It is important to distinguish between upper and lower motor neurone weakness. Power : grade 0–5, e.g. MRC scale; compare right with left testing  d d l l ( h ld lb f h kindividual muscle groups (shoulder, elbow, wrist, fingers, hip, knee  and ankle); it is often better to ask the patient to resist you  moving their limb than to move it in a certain direction e g whenmoving their limb than to move it in a certain direction, e.g. when  assessing triceps and biceps ‘Bend your arms like this and keep  them there’ Anas Bahnassi PhD CDM CDE 33
  34. 34. Power Shoulder abduction Wrist flexion Elbow flexion Finger flexion Elb t iElbow extension Fi bd tiFinger abduction
  35. 35. Classification of PowerClassification of Power 0 = Complete paralysis 1 Fli k f t ti1 = Flicker of contraction 2 = Movement possible with gravity excluded2 Movement possible with gravity excluded 3 = Movement possible against gravity but not against resistance 4 = Movement possible against resistance 5 = Normal power5 = Normal power
  36. 36. Neurological Assessment: Motor examination For motor examination, assess tone, power and reflexes, starting proximally and moving distally; compare right with left. Give the patient clear instructions when examining power. It is important to distinguish between upper and lower motor neurone weakness. Reflexes : strike the tendon, not the muscle; test biceps, triceps, supinator,  k d kl k l d d lknee and ankle jerks; an extensor plantar indicates a pyramidal  tract lesion; if there is no response, consider using a distraction  manoeuvre at the time of striking the tendon e g ask the patientmanoeuvre at the time of striking the tendon, e.g. ask the patient  to pull apart inversely clasped hands. Anas Bahnassi PhD CDM CDE 36
  37. 37. Reflexes
  38. 38. Classification of Reflexes 1. Absent 2. Reduced 3. Normal3. Normal 4. Increased4. Increased 5 Greatly increased5. Greatly increased Remember reinforcement manoeuvres when reflexes are absentRemember reinforcement manoeuvres when reflexes are absent
  39. 39. Neurological Assessment: Sensory examination  Sensory examination involves an assessment of pain, light touch, oprioception and vibration sense.  Assess pain using a Neurotip ®  (spinothalamic tract) and light touch using a  cotton ball (dorsal columns). Determine whether any abnormality is symmetrical or isolated. Anas Bahnassi PhD CDM CDE 39
  40. 40. Neurological Assessment: Cerebellar function  The cerebellum has an important role in the coordination of movement: • Perform the finger–nose test looking for ataxia, past pointing and intention  tremor (tremor on approach to the finger); heel–shin test should be  performed in lower limb examination  d l (d d d h k )• Test rapid alternating movements (dysdiadochokinesis)  • Compare right with left  • Remember that these tests are unreliable if the limb is weak  L k f t h i t l t t b ll di ith th• Look for nystagmus: horizontal nystagmus suggests cerebellar disease with the  fast phase towards the affected side  • Assess speech: disjointed and explosive (staccato) speech Anas Bahnassi PhD CDM CDE 40
  41. 41. Finger – Nose – Test:Finger – Nose – Test: • look for • intention tremor t i ti• past pointing Dysdiadochokinesis: l k f l d l t• look for slow and clumsy movement
  42. 42. Clinical Pharmacy VI:Clinical Pharmacy VI:yy First AidFirst Aid Anas Bahnassi PhD CDM CDEAnas Bahnassi PhD CDM CDE abahnassi@gmail.com http://www.twitter.com/abpharmp p http://www facebook com/pharmaprofhttp://www.facebook.com/pharmaprof http://www linkedin com/in/abahnassihttp://www.linkedin.com/in/abahnassi

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