NR 509 Midterm Exam / NR509 Midterm Exam Study Guide (Latest 2022/2023): Advanced Physica, Study Guides, Projects, Research of Nursing

Download NR 509 Midterm Exam / NR509 Midterm Exam Study Guide (Latest 2022/2023): Advanced Physica and more Study Guides, Projects, Research Nursing in PDF only on Docsity! NR I509 IMidterm IStudy IGuide IWeek I3 Ch. I1 ● Basic Iand IAdvanced IInterviewing ITechniques Basic I nterviewing ITechniques ● Active Ilistening: IActive Ilistening Imeans Iclosely Iattending Ito Iwhat Ithe Ipatient Iis Icommunicating, Iconnecting Ito Ithe Ipatient's Iemotional Istate, Iand Iusing Iverbal Iand Inonverbal Iskills Ito Iencourage Ithe Ipatient Ito Iexpand Ion Ihis Ior Iher Ifeelings Iand Iconcerns. Empathic Iresponses: IEmpathy Ihas Ibeen Idescribed Ias Ithe Icapacity Ito Iidentify Iwith Ithe Ipatient Iand Ifeel Ithe Ipatient's Ipain Ias Iyour Iown, Ithen Irespond Iin Ia Isupportive Imanner. Guided Iquestioning: IGuided Iquestions Ishow Iyour Isustained Iinterest Iin Ithe Ipatient's Ifeelings Iand Ideepest Idisclosures Iand Iallows Ithe Iinterviewer Ito Ifacilitate Ifull Icommunication, Iin Ithe Ipatient's Iown Iwords, Iwithout Iinterruption. Nonverbal Icommunication: INonverbal Icommunication Iincludes Ieye Icontact, Ifacial Iexpression, Iposture, Ihead Iposition Iand Imovement Isuch Ias Ishaking Ior Inodding, Iinterpersonal Idistance, Iand Iplacement Iof Ithe Iarms Ior Ilegs—crossed, Ineutral, Ior Iopen. Validation: IValidation Ihelps Ito Iaffirm Ithe Ilegitimacy Iof Ithe Ipatient's Iemotional Iexperience. Reassurance: IReassurance Iis Ian Iappropriate Iway Ito Ihelp Ithe Ipatient Ifeel Ithat Iproblems Ihave Ibeen Ifully Iunderstood Iand Iare Ibeing Iaddressed. Partnering: IWhen Ibuilding Irapport Iwith Ipatients, Iexpress Iyour Icommitment Ito Ian Iongoing Irelationship. Summarization: IGiving Ia Icapsule Isummary Iof Ithe Ipatient's Istory Iduring Ithe Icourse Iof Ithe Iinterview Ito Icommunicate Ithat Iyou Ihave Ibeen Ilistening Icarefully. Transitions: IInform Iyour Ipatient Iwhen Iyou Iare Ichanging Idirections Iduring Ithe Iinterview. Empowering Ithe Ipatient: IEmpower Ipatients Ito Iask Iquestions, Iexpress Itheir Iconcerns, Iand Iprobe Iyour Irecommendations Iin Iorder Ito Iencourage Ithem Ito Iadopt Iyour Iadvice, Imake Ilifestyle Ichanges, Ior Itake Imedications Ias Iprescribed. Advanced I nterview ITechniques 2 Determine Iscope Iof Iassessment: IFocused Ivs. IComprehensive: Comprehensive: IUsed Ipatients Iyou Iare Iseeing Ifor Ithe Ifirst Itime Iin Ithe Ioffice Ior Ihospital. IIncludes Iall Ithe Ielements Iof Ithe Ihealth Ihistory Iand Icomplete Iphysical Iexamination. Is Iappropriate Ifor Inew Ipatients Iin Ithe Ioffice Ior Ihospital Provides Ifundamental Iand Ipersonalized Iknowledge Iabout Ithe Ipatient IStrengthens Ithe Iclinician–patient Irelationship I IHelps Iidentify Ior Irule Iout Iphysical Icauses Irelated Ito Ipatient Iconcerns IProvides Ia Ibaseline Ifor Ifuture Iassessments Creates Ia Iplatform Ifor Ihealth Ipromotion Ithrough Ieducation Iand Icounseling IDevelops Iproficiency Iin Ithe Iessential Iskills Iof Iphysical Iexamination Focused: IFor Ipatients Iyou Iknow Iwell Ireturning Ifor Iroutine Icare, Ior Ithose Iwith Ispecific I“urgent Icare” Iconcerns Ilike Isore Ithroat Ior Iknee Ipain. IYou Iwill Iadjust Ithe Iscope Iof Iyour Ihistory Iand Iphysical Iexamination Ito Ithe Isituation Iat Ihand, Ikeeping Iseveral Ifactors Iin Imind: Ithe Imagnitude Iand Iseverity Iof Ithe Ipatient’s Iprob- Ilems; Ithe Ineed Ifor Ithoroughness; Ithe Iclinical Isetting—inpatient Ior Ioutpatient, Iprimary Ior Isubspecialty Icare; Iand Ithe Itime Iavailable. Is Iappropriate Ifor Iestablished Ipatients, Iespecially Iduring Iroutine Ior Iurgent Icare Ivisits Addresses Ifocused Iconcerns Ior Isymptoms Assesses Isymptoms Irestricted Ito Ia Ispecific Ibody Isystem Applies Iexamination Imethods Irelevant Ito Iassessing Ithe Iconcern Ior Iproblem Ias Ithoroughly Iand Icarefully Ias Ipossible Being Iaware Iof Iyour Ireactions Ihelps Idevelop Iyour Iclinical Iskills. Your Isuccess Iin Ieliciting Ithe Ihistory Ifrom Idifferent Itypes Iof Ipatients Igrows Iwith Iexperience, Ibut Itake Iinto Iaccount Iyour Iown Istressors, Isuch Ias Ifatigue, Imood, Iand Ioverwork. Self-care Iis Ialso Iimportant Iin Icaring Ifor Iothers. IEven Iif Ia Ipatient Iis Ichallenging, Ialways Iremember Ithe Iimportance Iof Ilistening Ito Ithe Ipatient Iand Iclarifying Ihis Ior Iher Iconcerns. Components Iof Ithe IHealth IHistory I nitial Iinformation Date Iand Itime Iof Ihistory-time Iis Iespecially Iimportant Iin Iemergent Isituations Identifying Idata-age, Igender, Imarital Istatus, Ioccupation-identify Isource Iof Ihistory Iie: Ifamily Imember, Ifriend Ietc. Reliability-usually Idocumented Iat Iend Iof Iinterview Iie: I“patient Iis Ivague Iwhen Idescribing Isymptoms”. Chief IComplaint(s) Try Ito Iquote Ithe Ipatients Iwords IPresent IIllness Complete, Iclear Iand Ichronological Idescription Iof Ithe Iproblem Iprompting Ithe Ipatient Ivisit IOnset, Isetting Iin Iwhich Iit Ioccurred, Imanifestations Iand Iany Itreatments 5 health Ievents, Isuch Ias Ipast Isurgery, Ihospitalization Ifor Ia Imajor Iprior Iillness, Ior Ia Iparent’s Ideath, Irequire Ifull Iexploration. IKeep Iyour Itechnique Iflexible. Remember Ithat Imajor Ihealth Ievents Idiscovered Iduring Ithe IReview Iof ISystems Ishould Ibe Imoved Ito Ithe IPresent IIllness Ior IPast IHistory Iin Iyour Iwrite-up. I■ ISome Iexperienced Iclinicians Ido Ithe IReview Iof ISystems Iduring Ithe Iphysical Iexamination, Iasking Iabout Ithe Iears, Ifor Iexample, Ias Ithey Iexamine Ithem. IIf Ithe Ipatient Ihas Ionly Ia Ifew Isymptoms, Ithis Icombination Ican Ibe Iefficient. IIf Ithere Iare Imultiple Isymptoms, Ihowever, Ithis Ican Idisrupt Ithe Iflow Iof Iboth Ithe Ihistory Iand Ithe Iexamination, Iand Inecessary Inote Itaking Ibecomes Iawkward 6 Subjective Iversus IObjective IData Subjective Iversus IObjective IData I(pg. I7) 7 Subjective IData I(symptoms) Objective IData I(signs) What Ithe Ipatient Itells Iyou What Iis Iobserved Iduring physical Iexamination Patients Ihistory, Ifrom IChief IComplaint Ithrough IReview Iof Systems Laboratory Iinformation, Itest Idata Documentation Documentation Ineeds Ito Ibe ICLEAR, ICONCISE, ICOMPREHENSIVE. SOAP I(subjective, Iobjective, Iassessment, I& Iplan) Inote Iis Iused Ifor Iproviders Iof Ivarious Ibackgrounds/specialties Ito Icommunicate Iwith Ieach Iother. Ch. I2 1. Clinical IDecision IMaking Critical IThinking Iand IReasoning IDifferential IDiagnoses Differential IDiagnosis: IA Ilist Iwith Ipotential Icauses Iof Ipatient Ispecific Iproblem/CC • A Ichief Icomplaint I(CC) Imust Ibe Iidentified Ifirst. • The Idifferential Idiagnosis Iwill Iinclude Iall Imedical Idisease Ithat Imay Ipossibly Iexplain Iproblem/ ICC. • The Idifferential Idiagnosis Imust Iinclude Ithe Imost Ilikely Idiagnosis Iand Ieven Iat Itimes Ithe Imost Iserious Idiagnoses Ithat Ihave Iserious Iconsequences Iif Iundiagnosed Iand Iuntreated. • The Idifferential Idiagnosis Ilist Ishould Ibegin Iwith Ithe Imost Ilikely Iexplanation Ior Ietiology Ifor Ithe Iproblem/CC. EX: IC/O Ivomiting Iblood 1. Peptic Iulcer 2. Cirrhosis Iwith Ibleeding Iesophageal Ivarices 3. Acute Ihemorrhagic Igastritis 10 Keep Ian Iopen Imind Itoward Iboth Ithe Ipatient Iand Ithe Iclinical Idata Always Iinclude I"the Iworst-case Iscenario" Iin Iyour Ilist Iof Ipossible Iexplanations Iof Ithe Ipatient's Iproblem, Iand Imake Isure Iit Ican Ibe Isafely Ieliminated Analyze Iany Imistakes Iin Idata Icollection Ior Iinterpretation Confer Iwith Icolleagues Iand Ireview Ithe Ipertinent Iclinical Iliterature Ito Iclarify Iuncertainties IApply Ithe Iprinciples Iof Ievaluating Iclinical Ievidence Ito Ipatient Iinformation Iand Itesting As Iyou Italk Iwith Iand Iexamine Ithe Ipatient, Iheighten Iyour Ifocus Ion Ithe Ipatient’s Imood, Ibuild, Iand Ibehavior 1. Reflect Ion Iyour Iapproach Ito Ithe Ipatient: IWhen Igreeting Ithe Ipatient Iidentify Iyourself Ias Ia Istudent, Ibeginners Ispend Imore Itime Iin Icertain Iareas Iand Ithat Iis Iok Ibut Ijust Iwarn Ithe Ipatient Ithat Iyou Imay Iwant Ito Ilisten Ito Itheir Iheart Ia Ilittle Ilonger Ibut Ithat Idoes Inot Imean Ianything Iis Iwrong Avoid Iinterpreting Iyour Ifindings, Iyou Iare Inot Ithe Ipatients Iprimary Icare Iprovider IAvoid Inegative Ireactions Ior Ishowing Idistaste Iwhen Ifinding Iabnormalities 2. Adjust Ithe Ilighting Iand Ithe Ienvironment: Iset Ithe Istage Iso Ithat Iboth Iyou Iand Ithe Ipatient Iare Icomfortable; Igood Ilighting Iand Ia Iquiet Ienvironment Ienhance Iwhat Iyou Isee Iand Ihear Ihowever Imay Ibe Ihard Ito Iarrange 3. Check Iyour Iequipment: IThe Ifollowing Iequipment Iis Ineeded: IAn Iophthalmoscope Iand Ian Iotoscope. IIf Iyou Iare Iexamining Ichildren, Ithe Iotoscope Icould Iallow Ipneumatic Iotoscopy. ● A Iflashlight Ior Ipenlight ● Tongue Idepressors A Iruler Iand Ia Iflexible Itape Imeasure, Ipreferably Imarked Iin Icentimeters I●Often Ia Ithermometer I●A Iwatch Iwith Ia Isecond Ihand ● A Isphygmomanometer ● A Istethoscope Iwith Ithe Ifollowing Icharacteristics: ● Ear Itips Ithat Ifit Isnugly Iand Ipainlessly. ITo Iget Ithis Ifit, Ichoose Iear Itips Iof Ithe Iproper Isize, Ialign Ithe Iear Ipieces Iwith Ithe Iangle Iof Iyour Iear Icanals, Iand Iadjust Ithe Ispring Iof Ithe Iconnecting Imetal Iband Ito Ia Icomfortable Itightness. I●Thick-walled Itubing Ias Ishort Ias Ifeasible Ito Imaximize Ithe Itransmission Iof Isound: I∼30 Icm I(12 Iinches), if Ipossible, Iand Ino Ilonger Ithan I38 Icm I(15 Iinches) ● A Ibell Iand Ia Idiaphragm Iwith Ia Igood Ichangeover Imechanism ● A Ivisual Iacuity Icard I●A Ireflex Ihammer I●Tuning Iforks, Iboth I128 IHz Iand I51 Cotton Iswabs, Isafety Ipins, Ior Iother Idisposable Iobjects Ifor Itesting Isensation Iand Itwo-point Idiscrimination I●Cotton Ifor Itesting Ithe Isense Iof Ilight Itouch ● Two Itest Itubes I(optional) Ifor Itesting Itemperature Isensation I●Gloves Iand Ilubricant Ifor Ioral, Ivaginal, Iand Irectal Iexaminations ● Vaginal Ispecula Iand Iequipment Ifor Icytologic Iand Ibacteriologic Istudies 11 ● Paper Iand Ipen Ior Ipencil, Ior Idesktop Ior Ilaptop Icomputer 4. Make Ithe Ipatient Icomfortable. IShow Isensitivity Ito Iprivacy Iand Ipatient Imodesty; Ithis Iconveys Irespect Ifor Ithe Ipatients I Ivulnerability 5. Observe Istandard Iand Iuniversal Iprecautions. 6. Choose Ithe Isequence, Iscope, Iand Ipositioning Iof Iexamination IFour Iclassic Itechniques Ifor Ifor Iphysical Iexamination: Inspection IPalpitation IPercussion IAuscultatio n Vital ISigns CCh. I6 ● Integumentary IAssessment Iand IModification Ifor IAge INormal IVS. IAbnormal IFindings Iand IInterpretation Melanoma IClinicians Ishould Iapply Ithe IABCDE Irule. I(page I178) IABCDE IRule: Asymmetry: I(compare Ione Iside Ito Ithe Iother) Border Iirregularity: Ilook Ifor Iragged, Inotched Ior Iblurred Color Ivariations: Imore Ithan I2 Icolors(blue Iblack) I(brown Ired), Iloss Iof Ipigment, Ior Iredness Diameter I>6 Imm: Isize Iof Ipencil Ieraser Evolving: Ichanging Irapidly Iin Isize, Isymptoms, Ior Imorphology I(usually Iasymmetrical) Also Ilook Ifor Ielevation, Ifirmness Ito Ipalpate, Igrowing Iprogressively Iover Iseveral Iweeks. Self Iskin Iexams Iare Irecommended Iby Ithe IACS Iand IAAD. IThey Ishould Ibe Idone Iin Ia Iwell Ilit Iroom Iwith Ia Ifull Ilength Imirror. I Patients Iwith Ia Ifamily Ihistory Iof Imelanoma, Iprior Ihistory Iof Imelanoma, Ior Ihistory Iof Ihigh Isun Iexposure Ishould Ido Iexams Imore Ifrequently. ITeach Ipatient Ithe Iappearance Iof Idifferent Iskin Icancers Iand Iprovide Iinternet Ireliable Iresources Ifor Ipatients. I Usually Iseen Iin Ifair Icolored Ipatients. 12 Primary Iand ISecondary ISkin ILesion INomenclature Psoriasis I(Hollier Ipage I139) Ihttps://www.aad.org/practicecenter/quality/clinical- Iguidelines/psoriasis ● Characterized Iby Ia Ichronic, Ipruritic, Iinflammatory Iskin Idisorder Icharacterized Iby Irapid Iproliferation Iof Iepidermal Icells. IExacerbations Iare Icommon. Most Icommon Iforms I(plaque Ipsoriasis, Iplaque Ilike Ilesions) Unknown Ietiology Ibut Icommon Iwith Ifamily Ihistory, IBeta Ihemolytic Istrep Iin Ichildren. IRisk Ifactors: Strep, Ifamily Ihx, Istress, Idiabetes, Iobesity, Ilocal Itrauma, Isunburn, Idrugs I(lithium, Ibeta Iblockers, Isystemic Isteroids/ Irebound Ieffect) Assessment Ifindings: Silvery Iwhite Iscales Ion Ierthymatous Ibase, Ipruritis, Icommon Idistribution Iof Ielbows, Iknees, Iscalp, Igluteal Icleft, Ifinger/toenails, Inails Imay Ibe Ipitted Iin I50% Iof Ipatients IPositive IAuspitz Isign I(bleeding Iwhen Ilesions Iscraped) Intergluteal Ileasions Iare Ipink/smooth *PROFOUND INEGATIVE ISELF I MAGE/ ISELF IESTEEM* Differential Idiagnosis: ● Scalp- ISeborrheic Idermatitis ITrunk- Ipityriasis Irosea, Itinea Icorporis ICandida Iinfections Contact Idermatitis IEczema Diagnostic Istudies: ● Swab Ifor Istrep, Ibiopsy, IESR/CRP Iusually Ielevated 15 **Note Ithat Ithe Itonsillar, Isubmandibular, Iand Isubmental Inodes Idrain Iportions Iof Ithe Imount Iand Ithroat Ias Iwell Ias Ithe Iface. **Lymphatic Idrainage Ipatterns Iare Ihelpful Ifor Iassessing Ipossible Imalignancy Ior Iinfection. ITo Ilook Ifor Ithis, Ilook Ifor Ienlargement Iof Ithe Ineighboring Iregional Ilymph Inodes; Iwhen Ia Inode Iis Ienlarged Ior Itender, Ilook Ifor Isource Iin Iits Inearby Idrainage Iarea. Techniques Ifor Iexamining Ilymph Inodes: First Iinspect Ithe Ineck- Iis Iit Isymmetrical? IDo Iyou Isee Iany Imasses Ior Iscars? ILook Ifor Ienlargement Iof Ithe Iparotid Ior Isubmandibular Iglands, Iand Inote Iany Ivisible Ilymph Inodes. **If Iyou Isee Ia Iscar Ifrom Ia Ipast Ithyroid Isurgery, Ithis Iis Ia Iclue Ito Ian Iunsuspected Ithyroid Ior Iparathyroid Idisease. Second, Ipalpate Ithe Ilymph Inodes: 1) Use Ipads Iof Iyour Iindex Ifinger Iand Imiddle Ifingers, Ipress Igently, Imoving Ithe Iskin Iover Ithe Iunderlying Itissues Iin Ieach Iarea. Make Isure Ithe Ipatient Iis Irelaxed, Iwith Ithe Ineck Iflexed Islightly Iforward Iand Iif Ineeded, Iturned Islightly Itoward Ithe Iside Ibeing Iexamined. **You Ican Iusually Iexamine Iboth Isides Iat Ionce, Inoting Iboth Ithe Ipresence Iof Ilymph Inodes Ias Iwell Ias Iasymmetry. IHowever, Ifor Ithe Isubmental Inode, Iit Iis Ihelpful Ito Ifeel Iwith Ione Ihand Iwhile Ibracing Ithe Itop Iof Ithe Ihead Iwith Ithe Iother Ihand. Sequence Ifor Ithe Ifollowing Inodes: ⮚ Preauricular- Iin Ifront Iof Ithe Iear Posterior Iauricular- Isuperficial Ito Ithe Imastoid Iprocess I(behind Ithe Iear). IOccipital- Iat Ithe Ibase Iof Ithe Iskull Iposteriorly Tonsillar- Iat Ithe Iangle Iof Ithe Imandible Submandibular- Imidway Ibetween Ithe Iangle Iand Ithe Itip Iof Ithe Imandible. IThese Inodes Iare Iusually Ismaller Iand Ismoother Ithan Ithe Ilobulated Isubmandibular Igland Iagainst Iwhich Ithey Ilie. Submental- Iin Ithe Imidline Ia Ifew Icm’s Ibehind Ithe Itip Iof Ithe Imandible. ISuperficial Icervical- Isuperficial Ito Ithe Isternocleidomastoid Posterior Icervical- Ialong Ithe Ianterior Iedge Iof Ithe Itrapezius Deep Icervical Ichain- Ideep Ito Ithe Isternocleidomastoid Iand Ioften Iinaccessible Ito Iexamination. **Hook Iyour Ithumb Iand Ifingers Iaround Ieither Iside Iof Ithe Isternocleidomastoid Imuscle Ito Ifind Ithem. Supraclavicular- Ideep Iin Ithe Iangle Iformed Iby Ithe Iclavicle Iand Ithe Isternocleidomastoid. **Enlargement Iof Ithe Isupraclavicular Inode, Iespecially Ion Ithe Ileft, Isuggest Ipossible Imetastasis Ifrom Ia Ithoracic Ior Ian Iabdominal Imalignancy. Note Ithe Ifollowing Iwhen Iassessing Ilymph Inodes: ⮚ Node Isize Shape Delimitation I(discrete Ior Imatted Itogether) IMobility Consistency 16 Tenderness Small, Imobile, Idiscrete, Inontender Inodes, Isometimes Icalled I“shotty” Iare Ifrequently Ifound Iin Inormal Ipeople. Describe Ienlarged Ilymph Inodes Iin Itwo Idimensions, Imaximal Ilength Iand Iwidth, Ifor Iexample, I1 Icm Ix I2 Icm. IAlso Inote Iany Ioverlying Iskin Ichanges I(erythema, Iinduration, Idrainage Ior Ibreakdown). If Ienlarged Ior Itender Inodes, Iif Iunexplained Icall Ifor I(1) Ire-examination Iof Ithe Iregions Ithey Idrain Iand (2) careful Iassessment Iof Ithe Ilymph Inodes Iin Iother Iregions Ito Iidentify Iregional Ifrom Igeneralized Ilymphadenopathy. Techniques Ifor Ipreauricular Iand Icervical Ilymph Inodes: ⮚ Using Ithe Ipads Iof Ithe Isecond Iand Ithird Ifingers Ipalpate Ithe Ipreauricular Inodes Iwith Ia Igentle Irotary Imotion. IThen Iexamine Ithe Iposterior Iauricular Iand Ioccipital Ilymph Inodes. **Tender Inodes Isuggest Iinflammation; Ihard Ior Ifixed Inodes Isuggest Imalignancy. Palpate Ithe Ianterior Isuperficial Iand Ideep Icervical Ichains, Ilocated Ianterior Iand Isuperficial Ito Ithe Isternocleidomastoid. IThen Ipalpate Ithe Iposterior Icervical Ichain Ialong Ithe Itrapezius Iand Ialong Ithe Isternocleidomastoid. Flex Ithe Ipatient’s Ineck Islightly Iforward Itoward Ithe Iside Ibeing Iexamined. Examine Ithe Isupraclavicular Inodes Iin Ithe Iangle Ibetween Ithe Iclavicle Iand Ithe Isternocleidomastoid. ***If Iyou Ifeel Isupraclavicular Ilymph Inodes, Ia Ithrough Iwork-up Iis Iwarranted. Generalized Ilymphadenopathy Iis Iseen Iin Imultiple Iinfectious, Iinflammatory, Ior Imalignant Iconditions Isuch Ias IHIV Ior IAIDS, Iinfectious Imononucleosis, Ilymphoma, Ileukemia, Iand Isarcoidosis. Occasionally, Iyou Imistake Ia Iband Iof Imuscle Ior Ian Iartery Ifor Ia Ilymph Inode. IUnlike Ia Imuscle Ior Ian Iartery, Iyou Ishould Ibe Iable Ito Iroll Ia Inode Iin Itwo Idirections: Iup Iand Idown, Iand Iside Ito Iside. INeither Ia Imuscle Inor Ian Iartery Iwill Ipass Ithis Itest. Cranial INerves HEENT IAssessment Iand IModification Ifor IAge INormal IVS. IAbnormal IFindings Iand I nterpretation IVisual IAcuity Visual IAcuity I(Pg. I231) To Itest Ivisual Iacuity, Iyou Iare Ito Iuse Ia Iwell-lit ISnellen Ieye Ichart, Iif Ipossible IPatient Imust Iwear Icorrection Ilenses I(glasses/contacts) Iif Iavailable IPatient Iis Ito Ibe Ipositioned I20 Ifeet Iaway Ifrom ISnellen Ieye Ichart Patient Imust Icover Ione Ieye Iat Ia Itime Iand Itest Ieach Ieye Iindividually Iand Ithen Itest Ivision Iwith Iboth Ieyes Iuncovered Patient Imust Iidentify Ithe Ismallest Iline Iof Iprint Ipossible Iwhere Ithey Ican Iidentify Imore 17 than Ihalf Ithe Iletters --Visual IAcuity Iis Iexpressed Ias Itwo Inumbers I(20/30): Ithe Ifirst Iindicates Ithe Idistance Iof Ithe Ipatient Ifrom Ithe Ichart, Iand Ithe Isecond Inumber Iis Ithe Idistance Iat Iwhich Ia Inormal Ieye Ican Iread Ithe Iline Iof Iletters Testing Inear Ivision Iwith Ia Ihand-held Icard Iat Ithe Ibedside Ican Ihelp Iidentify Ithe Ineed Ifor Icorrection Ilenses Ifor Ireading I(card Ito Ibe Iheld I14 Iinches Ifrom Ipatients’ Ieyes) Glaucoma IEpistaxis Retinal I ssues Retinal Iartery Ihypertension, Iincreased Ipressure Idamages Ithe Ivascular Iendothelium, Ileading Ito Ideposition Iof Iplasma Imacromolecules Iand Ithickening Iof Ithe Iarterial Iwall, Icausing Ifocal Iand Igeneralized Inarrowing Iof Ithe Ilumen Iand Ilight Ireflex. Copper Iwiring: Isometimes Ithe Iarteries, Iespecially Ithose Iclose Ithe Idisc, Ibecome Ifull Iand Isomewhat Itortuous Iand Idevelop Ian Iincreased Ilight Ireflex Iwith Ia Ibright Icoppery Iluster, Icalled Icopper Iwiring. Silver Iwiring: Ioccasionally Ithe Iwall Iof Ia Inarrowed Iartery Ibecomes Iopaque Iso Ithere Iis Ino Ivisible Iblood Icalled Isilver Iwiring. AV ICrossing Iis Iwhen Ithe Iarterial Iwalls Ilose Itheir Itransparency, Ichanges Iappear Iin Ithe Iarteriovenous Icrossing. IDecreased Itransparency Iof Ithe Iretina Iprobably Ialso Icontributes Ito IConcealment Ior IAV INicking Iand ITapering. Concealment Ior IAV INicking: Ithe Ivein Iappears Ito Istop Iabruptly Ion Ieither Iside Iof Ithe Iartery. 20 Listen Ifor Iany Iadded, Ior Iadventitious, Isounds Ithat Iare Isuperimposed Ion Ithe Iusual Ibreath Isounds. IDetection Iof Iadventitious Isounds—crackles I(sometimes Icalled Irales), Iwheezes, Iand Irhonchi—is Ian Iimportant Ifocus Iof Iyour Iexamination, Ioften Ileading Ito Idiagnosis Iof Icardiac Iand Ipulmonary Iconditions. o Crackles Ican Iarise Ifrom Iabnormalities Iof Ithe Ilung Iparenchyma I(pneumonia, Iinterstitial Ilung Idisease, Ipulmonary Ifibrosis, Iatelectasis, Iheart Ifailure) Ior Iof Ithe Iairways I(bronchitis, Ibronchiectasis) o Wheezes Iarise Iin Ithe Inarrowed Iairways Iof Iasthma, ICOPD, Iand Ibronchitis. o Many Iclinicians Iuse Ithe Iterm I“rhonchi” Ito Idescribe Isounds Ifrom Isecretions Iin Ilarge Iairways Ithat Imay Ichange Iwith Icoughing. 1. In Isome Inormal Ipeople, Icrackles Imay Ibe Iheard Iat Ithe Ianterior Ilung Ibases Iafter Imaximal Iexpiration. ICrackles Iin Idependent Iportions Iof Ithe Ilungs Imay Ialso Ioccur Iafter Iprolonged Irecumbency. 2. If Iyou Ihear Iwheezes Ior Irhonchi, Inote Itheir Itiming Iand Ilocation. IDo Ithey Ichange Iwith Ideep Ibreathing Ior Icoughing? IBeware Iof Ithe Isilent Ichest, Iin Iwhich Iair Imovement Iis Iminimal. IIn Ithe Iadvanced Iairway Iobstruction Iof Isevere Iasthma, Iwheezes Iand Ibreath Isounds Imay Ibe Iabsent Idue Ito Ilow Irespiratory Iairflow I(the I“silent Ichest”), Ia Iclinical Iemergency. 3. Note Ithat Itracheal Isounds Ioriginating Iin Ithe Ineck Isuch Ias Istridor Iand Ivocal Icord Idysfunction Ican Ibe Itransmitted Ito Ithe Ichest Iand Imistaken Ifor Iwheezing, Ileading Ito Iinappropriate Ior Idelayed Itreatment. 4. Note Iany Ipleural Irubs, Iwhich Iare Icoarse, Igrating Ibiphasic Isounds Iheard Iprimarily Iduring Iexpiration. Pneumonia Acute Iillness: Itiming Ivaries Iwith Icausative Iagent Associated ISymptoms: IPleuritic Ipain, Icough, Isputum, Ifever, Ithough Inot Inecessarily Ipresent Mycoplasma Iand IViral IPneumonias Cough Iand ISputum: IDry Iand Ihacking Ioften Iwith Imucoid Isputum IAssociated ISymptoms Iand Setting: IAcute Ifebrile Iillness, Ioften Iwith Imalaise, Iheadache, Iand Ipossibly Idyspnea Bacterial IPneumonias Cough Iand ISputum: ISputum Iis Imucoid Ior Ipurulent; Imay Ibe Iblood-streaked, Idiffusely Ipinkish, Ior Irusty 21 Associated ISymptoms Iand ISetting: IAcute Iillness Iwith Ichills, Ioften Ihigh Ifever, Idyspnea, Iand Ichest Ipain. ICommonly Ifrom IStreptococcus Ipneumonia, IHaemophilus Iinfluenza, IMoraxella Icatarrhalis; IKlebsiella Iin Ialcoholism (Chapter I8 IThe IThorax Iand ILungs) Asthma ICh. I16 Musculoskeletal IAssessment Iand IModification Ifor IAge INormal IVS. IAbnormal IFindings Iand IInterpretation IBack Ipain Low IBack IPain. IThe Iestimated Ilifetime Iprevalence Iof Ilow Iback Ipain Iin Ithe IUnited IStates Ipopulation Iis Iover I80%. ISpinal Idisorders Iare Iamong Ithe Imost Ifrequent Ireasons Ifor Iadult Ioutpatient Ivisits, Iand Ithe Iannual IU.S. Ieconomic Icosts Iattributed Ito Idiagnosing Iand Imanaging Ilow Iback Ipain Iand Ilost Iproductivity Iexceed I$100 Ibillion. IMost Ipatients Iwith Iacute Ilow Iback Ipain Iget Ibetter Iwithin I6 Iweeks; Ifor Ipatients Iwith Inonspecific Isymptoms, Iclinical Iguidelines Iemphasize Ireassurance, Istaying Iactive, Ianalgesics, Imuscle Irelaxants, Iand Ispinal Imanipulation Itherapy.Overall, Iabout I10% Ito I15% Iof Ipatients Iwith Iacute Ilow Iback Ipain Idevelop Ichronic Isymptoms, Ioften Iassociated Iwith Ilong-term Idisability. IFactors Iassociated Iwith Ipoor Ioutcomes Iinclude Iinappropriate Ibeliefs Ithat Ilow Iback Ipain Iis Ia Iserious Iclinical Icondition, Imaladaptive Ipain-coping Ibehaviors I(avoiding Iwork, Imovement, Ior Iother Iactivities Ifor Ifear Iof Icausing Iback Idamage), Imultiple Inonorganic Iphysical Iexamination Ifindings, Ipsychiatric Idisorders, Ipoor Igeneral Ihealth, Ihigh Ilevels Iof Ibaseline Ifunctional Iimpairment, Iand Ilow Iwork Isatisfaction. IReview Ithe Inonorganic Iphysical Ifindings I(the IWaddell Isigns) Ion Ip. I674.31 IAppropriate Itreatments Ifor Ichronic Ilow Iback Ipain Iinclude Itreatments Ifor Iacute Ilow Iback Ipain Ias Iwell Ias Iback Iexercises Iand Ibehavioral Itherapy. Opioids Ishould Ibe Iused Icautiously, Igiven Itheir Iadverse Ieffects Iand Irisks Ifor Iabuse. Start Iby Iasking I“Do Iyou Ihave Iany Iback Ipain?,”—at Ileast I40% Iof Iadults Ihave Ilow Iback Ipain Iat Ileast Ionce Iduring Itheir Ilifetime, Iusually Ibetween Ithe Iages Iof I30 Iand I50 Iyears, Iand Ilow Iback Ipain Iis Ione Iof Ithe Imost Icommon Ireasons Ifor Ioffice Ivisits. IThere Iare Inumerous Iclinical Iguidelines, Ibut Imost Icategorize Ilow Iback Ipain Iinto Ithree Igroups: Inonspecific I(>90%), Inerve Iroot Ientrapment Iwith Iradiculopathy Ior Ispinal Istenosis I(∼5%), Iand Ipain Ifrom Ia Ispecific Iunderlying Idisease I(1% Ito I2%).4,20 INote Ithat Ithe Iterm I“nonspecific Ilow Iback Ipain” Iis Ipreferred Ito I“sprain” Ior I“strain.” IUsing Iopen-ended Iquestions, Iget Ia Iclear Iand Icomplete 22 picture Iof Ithe Iproblem, Iespecially Ithe Ilocation Iof Ipain Iand Iprior Ihistory Iof Ipain! Knee IPain The Iknee Ijoint Iis Ithe Ilargest Ijoint Iin Ithe Ibody. IIt Iis Ia Ihinge Ijoint Iinvolving Ithree Ibones: Ithe Ifemur, Ithe Itibia, Iand Ithe Ipatella I(or Iknee Icap), Iwith Ithree Iarticular Isurfaces, Itwo Ibetween Ithe Ifemur Iand Ithe Itibia Iand Ione Ibetween Ithe Ifemur Iand Ithe Ipatella. INote Ihow Ithe Itwo Irounded Icondyles Iof Ithe Ifemur Irest Ion Ithe Irelatively Iflat Itibial Iplateau. IThere Iis Ino Iinherent Istability Iin Ithe Iknee Ijoint Iitself, Imaking Iit Idependent Ion Ifour Iligaments Ito Ihold Iits Iarticulating Ifemur Iand Itibia Iin Iplace. IThis Ifeature, Iin Iaddition Ito Ithe Ilever Iaction Iof Ithe Ifemur Ion Ithe Itibia Iand Ithe Ilack Iof Ipadding Ifrom Ioverlying Ifat Ior Imuscle, Imakes Ithe Iknee Ihighly Ivulnerable Ito Iinjuries. Pain Iis Ia Icommon Icomplaint Iin Iknee Iproblems, Iand Ilocalizing Ithe Istructure Icausing Ipain Iis Iimportant Ifor Iaccurate Ievaluation. Tenderness Iover Ithe Itendon Ior Iinability Ito Iextend Ithe Iknee Isuggests Ia Ipartial Ior Icomplete Itear Iof Ithe Ipatellar Itendon. Pain Iand Icrepitus Iarise Ifrom Ithe Iroughened Iundersurface Iof Ithe Ipatella Ias Iit Iarticulates Iwith Ithe Ifemur. ISimilar Ipain Imay Ioccur Iwhen Iusing Ithe Istairs, Ior Igetting Iup Ifrom Ia Ichair. Pain Iwith Icompression Iand Ipatellar Imovement Iduring Iquadriceps Icontraction Ioccurs Iin Ichondromalacia. ITwo Iof Ithe Ithree Ifindings Iare Imost Idiagnostic Iof Ipatellofemoral Ipain Isyndrome: Ipain Iwith Iquadriceps Icontraction; Ipain Iwith Isquatting; Iand Ipain Iwith Ipalpation Iof Ithe Iposteromedial/or Ilateral Ipatellar Iborder. You Iwill Ioften Ineed Ito Itest Iligamentous Istability Iand Iintegrity Iof Ithe Imedial Iand Ilateral Imenisci, Ithe IMCL Iand ILCL, Ithe Ipatellar Itendon, Iand Ithe IACL Iand IPCL I(not Ipalpable), Iparticularly Iwhen Ithere Iis Ia Ihistory Iof Itrau- Ima Ior Iknee Ipain. IAlways Iexamine Iboth Iknees Iand Icompare Ifindings. ACL Itears Iare Inotably Imore Ifrequent Iin Iwomen, Iattributed Ito Iligamentous Ilaxity Irelated Ito Iestrogen Icycling Iand Ito Idifferences Iin Ianatomy Iand Ineuro- Imuscular Icontrol. IACL Iinjury Iprevention Iprograms Iare Inow Icommon. 25 Warmth 1.) ISwelling Redness: Iredness Ioverlying Iskin Iis Ithe Ileast Icommon Isign Iof Iinflammation Inear Ithe Ijoints Iand Iis Iusually Iseen Iin Imore Isuperficial Ijoints Ilike Ifingers, Itoes, Iand Iknees. I***redness Iover Ia Itender Ijoint Isuggests Iseptic Ior Icrystalline Iarthritis, Ior Ipossibly IRA Pain Ior Itenderness Palpate Ithe Imetatarsophalangeal I(MTP) Ijoints Ifor Itenderness. ICompress Ithe Iforefoot Ibetween Ithe Ithumb Iand Ifingers. IExert Ipressure Ijust Iproximal Ito Ithe Iheads Iof Ithe Ifirst Iand Ififth Imetatarsals. I***Tenderness Ion Icompression Iis Ian Iearly Isign Iof IRA. Acute IRA I: Itender, Ipainful, Istiff Ijoints Iin IRA, Iusually Iwith Isymmetric Iinvolvement Ion Iboth Isides Iof Ithe Ibody. IThe Idistal Iinterphalangeal I(DIP), Imetacarpophalangeal I(MCP), Iand Iwrist Ijoints Iare Ithe Imost Ifrequently Iaffected. INote Ithe Ifusiform Ior Ispindle-shaped Iswelling Iof Ithe IPIP Ijoints Iin Iacute Idisease. Chronic IRA: IIn Ichronic Idisease, Inote Ithe Iswelling Iand Ithickening Iof Ithe IMCP Iand IPIP Ijoints. IROM Ibecomes Ilimited, Iand Ifingers Iamy Ideviate Itoward Ithe Iulnar Iside. IThe Iinterosseous Imuscles Iatrophy. IThe Ifingers Imay Ishow I“swan Ineck” Ideformities I(hyperextension Iof Ithe IPIP Ijoints Iwith Ifixed Iflexion Iof Ithe Idistal Iinterphalangeal I(DIP) Ijoints. ILess Icommon Iis Ia Iboutonniere Ideformity I(persistent Iflexion Iof Ithe IPIP Ijoint Iwith Ihyperextension Iof Ithe IDIP Ijoint). IRheumatoid Inodules Iare Iseen Iin Ithe Iacute Ior Ithe Ichronic Istage. ISubcutaneous Inodules Imay Idevelop Iat Ipressure Ipoints Ialong Ithe Iextensor Isurface Iof Ithe Iulna Iin Ipatients Iwith IRA Ior Iacute IRheumatic Ifever. IThey Iare Ifirm Iand Inontender. IThey Iare Inot Iattached Ito Ithe Ioverlying Iskin Ibut Imay Ibe Iattached Ito Ithe Iunderlying Iperiosteum. IThey Ican Idevelop Iin Ithe Iarea Iof Ithe Iolecranon Ibursa, Ibut Ioften Ioccur Imore Idistally. CCh. I17 Neurological IAssessment Iand IModification Ifor IAge The Ineurological Iexam Ican Ibe Iorganized Iinto I6 Ior I7 Icategories: (1) mental Istatus: Iused Ito Iestablish Ithe Ireliability Iof Ithe Irest Iof Ithe Ineuro Iexam. Most Iof Ithe Imental Istatus Iassessment Ican Ibe Icompleted Ivia Iobservation Iand Ithrough 26 their Ianswers Ito Iyour Iquestions Iduring Ihistory Itaking. I(making Ieye Icontact, Idoes Inot Idrift Ior Ineed Ithings Irepeated, Iable Ito Iconverse Inormally, Iand Ianswers Iquestions Iabout Imedical Ihistory Iand Irecent Ieventing Iin Ia Iconsistent Imanner) 7 Iareas Iof Imental Istatus Ineed Ito Ibe Iconsidered: 1. Level Iof Iawareness. 2. Attentiveness: I s Ithe Ipatient Ipaying Iattention Ito Iyou Iand Iyour Iquestions Ior Iis Ihe Idistractible Iand Irequiring Ire-focusing? 3. Orientation: Ito Iself, Iplace, Itime. IDisorientation Ito Itime Itypically Ioccurs Ibefore Idisorientation Ito Iplace Ior Iperson. IDisorientation Ito Iself Iis Itypically Ia Isign Iof Ipsychiatric Idisease. 4. Speech I& Ilanguage: Iincludes Ifluency, Irepetition, Icomprehension, Ireading, Iwriting, Inaming. 5. Memory: Iincludes Iregistration Iand Iretention. 6. Higher Iintellectual Ifunction: Iincludes Igeneral Iknowledge, Iabstraction, Ijudgment, Iinsight, Ireasoning. 7. Mood Iand Iaffect: IThe Iprimary Ipurpose Iof Iassessing Imood Iand Iaffect Iin Ithe Ineurological Iexam Iis Ito Idetermine Iif Ipsychiatric Idisease Imay Ibe Iinterfering Iwith Ithe Ineurological Iassessment. IWe’re Inot Ilooking Ifor Ia IDSM-IV Ipsychiatric Idiagnosis. (2) Cranial Inerves: ISEE IBELOW IFOR IA ILIST Please Inote: I1) Itheir Iabsence Idoes Inot Inecessarily Iprovide Iuseful Iinformation I(e.g., Isense Iof Ismell Iand Itaste Imay Ibe Iabsent Ior Ireduced Iin Ithe Isetting Iof Ian Iupper Irespiratory Iinfection; Igag Ireflex Iis Iabsent Iin Imany Ihospitalized Ipatients Ias Iwell Ias Inormal Ielderly Ipatients) Ior I2) Itesting Imultiple Ifunctions Iof Ia Iparticular Icranial Inerve Imay Inot Iadd Inew Iinformation I(e.g., Iif Ipupillary Ireaction Ito Ilight Iis Ipresent, Ithen Iassessing Ipupillary Ireaction Ito Iaccommodation Idoes Inot Igive Iany Inew Iinformation). IAgain, Ithough, Iyou Ineed Ito Iknow Ihow Ito Iperform Ithese Itests Iin Ithe Ievent Ithat Ithey Iare Irelevant Ito Ithe Ipatient’s Icomplaints Ior Iillness. IOlfaction Imust Ibe Iassessed Iif Ithe Ipatient Icomplains Iof Ia 27 disturbance Iin Itaste Ior Ismell Ior Iif Ia Ilesion Iof Ithe Iolfactory Igroove Iis Isuspected. ISimilarly, Itaste Ishould Ibe Iassessed Iwhen Ithere Iis Ia Ipertinent Icomplaint I(though Ithe Icomplaint Iusually Iturns Iout Ito Ibe Idue Ito Iloss Iof Ismell). IPupillary Iresponse Ito Iaccommodation Imust Ibe Iassessed Iif Ithe Ipupils Ido Inot Ireact Ito Ilight. ICorneal Ireflex Imust Ibe Itested Iif Ithe Ipatient Icomplains Iof Isensory Idisturbance Iin Ithe Iface I(because Iit Iis Ian Iobjective Iindication Iof Itrigeminal Inerve Idysfunction Iwhereas Isensory Icomplaints Iare Isubjective) Ior Iif Ithe Ipatient Iis Icomatose I(because Iyou Icannot Iask Ithe Ipatient Iif Ifacial Isensation Iis Isymmetric). (3) Motor Isystem: Strength-shoulder Iabduction, Ielbow Iextension, Iwrist Iextension, Ifinger Iabduction, Ihip Iflexion, Iknee Iflexion, Iankle Idorsiflexion Gait- Icasual, Iheel Iwalk, Itoe Iwalk, Itandem Iwalk Coordination- Ifine Ifinger Imovements, Ifinger Ito Inose, Iheel-knee-shin The Imotor Iexam Iis Iaffected Inot Ionly Iby Imuscle Istrength, Ibut Ialso Iby Ieffort, Icoordination, Iand Iextrapyramidal Ifunction. ITests Iof Idexterity Iand Icoordination Iare Imost Isensitive Ito Ipicking Iup Iupper Imotor Ineuron Iand Icerebellar Iabnormalities, Iwhereas Idirect Istrength Itesting Iis Imore Isensitive Ito Ilower Imotor Ineuron Idysfunction. IOther Iaspects Iof Ithe Imotor Iexam Iinclude I(1) Ipatterns Iof Imuscle Iatrophy Ior Ihypertrophy, I(2) Iassessment Iof Imuscle Itone I(e.g., Ispastic Ior Iclasp Iknife, Irigid Ior Ilead Ipipe, Iflaccid) Iwith Ipassive Imovement Iof Ijoints Iby Ithe Iexaminer, I(3) Idisturbances Iof Imovement I(e.g., Ithe Islowness Iand Ireduced Ispontaneity Iof Imovement Iin Iparkinsonism), I(4) Iendurance Iof Ithe Imotor Iresponse I(e.g., Ithe Ifatigability Iof Imyasthenia Igravis), Iand I(5) Iwhether Iany Ispontaneous Imovements Iare Ipresent I(e.g., Ifasciculations Ior Ibrief Itwitches Iwithin Ithe Imuscle). IStrength Iof Iproximal Iand Idistal Imuscles Iin Iall Ilimbs Ishould Ibe Iassessed. IFor Ithe Iscreening Iexam, Ispecific Imuscle Itesting Iin Ithe Ilower Iextremities Iis Inot Inecessary Ifor Ipatients Iwho Iare Iable Ito Iwalk Inormally I(including Ion Ithe Itoes Iand Iheels) Iand Ito Iget Iout Iof Ia Ichair Iwithout Iusing Itheir Iarms Ito Ipush Ithemselves Iup. IWhen Itesting Iindividual Imuscle Istrength, Ibe Isure Ito I(1) Iposition Ithe Ilimb Iin Isuch Ia Iway Ias Ito Ipermit Ithe Imuscle Ibeing Iexamined Ito Iact Idirectly Iand Ito Iminimize Ithe Irecruitment Iof Iother Imuscles Ihaving Isimilar Ifunction Iand I(2) Ialways Igive Iyourself Ithe Iadvantage. IFor Iexample, Itest Ithe Iiliopsoas Iby Ipushing Idown Ion Ithe Ifoot Iof Ithe Ioutstretched Ileg Irather Ithan Ion Ithe Ithigh. IBe Iaware Iof Inormal Ivariability Iin Istrength Ibased Ion Iage, Isex, Ihandedness I(i.e., Ithe Imuscles Ion Ithe Idominant Iside Imay Ibe Istronger), Iand Imuscle I(e.g., Iin Ia Ipatient Iwith Inormal Istrength, Iyou Ishould Inever Ibe Iable Ito Iovercome Ithe Iankle Iplantar Iflexors Ibut Iyou Iwill Ilikely Ibe Iable Ito Iovercome Ithe 30 eyes Iopen Iand Ithen Ito Iclose Ithe Ieyes. IAn Iabnormal Iresponse I(“positive IRomberg Isign”) Iis Ifor Ithe Ipatient Ito Ibe Iable Ito Istand Iupright Iwhen Ithe Ieyes Iare Iopen, Ibut Ito Isway/fall Iwhen Ithe Ieyes Iare Iclosed. IContrary Ito Ipopular Ibelief, Ia Ipositive IRomberg Isign Iis Inot Ian Iindication Iof Icerebellar Idisease—the Ipatient Iwith Icerebellar Ior Iother Imotor Idysfunction Iwill Ihave Ia Ihard Itime Imaintaining Ian Iupright Iposture Iwith Ithe Ifeet Itogether Iregardless Iof Iwhether Ithe Ieyes Iare Iopen Ior Iclosed. IRather, Iit Iis Ian Iindication Iof Ieither Iimpaired Iproprioception Ior Ivestibular Idysfunction. IThere Iare Ithree Isensory Iinputs Ito Imaintain Itruncal Istability—vision, Iproprioception, Iand Ivestibular Ifunction. IPatients Iwith Iimpairment Iof Ione Iof Ithese Isystems Iare Iusually Iable Ito Icompensate Iand Imaintain Itruncal Istability. IThey Icannot Iusually Icompensate Iwhen Ia Isecond Isystem I(vision, Iwhen Ithe Ieyes Iare Iclosed) Iis Iremoved. IFor Ithe Iscreening Isensory Iexam, Iyou Ishould Iperform Ione Itest Iof Isuperficial Isensation I(pain Ior Itemperature) Iand Ione Iof Ideep Isensations I(proprioception Iis Imore Iuseful Ithan Ivibration Isince Idistal Ivibratory Isense Iis Ilost Iin Iotherwise Ihealthy Ielderly Ipatients) Iin Ieach Ilimb. ISince Ithe Imajority Iof Iasymptomatic Isensory Ideficits Iyou Iwill Ipick Iup Iare Ineuropathies Iand Ithe Imajority Iof Ithese Ibegin Idistally, Itesting Iat Ithe Imost Idistal Iaspect Iof Ithe Ilimb Iis Iusually Isufficient. (6) Coordination Iand Igait Test Icoordination Iat Irest Iand Iwith Iaction, Iin Ithe Itrunk I(e.g., Iability Ito Imaintain Ian Ierect Iposture), Iand Iin Ithe Ilimbs. IImpairment Iof Icoordination Imay Ibe Idetected Ithrough Isimple Iobservation Iof Ithe Ipatient Iperforming Iroutine Iacts Isuch Ias Isigning Ihis Iname, Ireaching Ifor Iobjects, Ior Igetting Ionto Ithe Iexamination Itable. ISpecific Itests Ito Ilook Ifor Iimpaired Icoordination Iin Ithe Ilimbs Iinclude Ifinger-to-nose I(patient Ialternately Itouches Iyour Ioutstretched Ifinger Iand Ihis Inose), Iheel-knee-shin I(patient Iruns Ithe Iheel Iof Ione Ifoot Idown Ithe Ishin Iof Ithe Iother), Irapid Ialternating Imovements I(patient Ialternately Itaps Ithe Idorsal Iand Iplantar Isurface Iof Ione Ihand Ionto Ithe Iother Ihand), Iand Ifinger Ior Itoe Itapping. IIn Iall Icases, Iyou Ishould Ibe Ilooking Iat Irhythm, Isteadiness, Ispeed, Iand Iprecision Iof Imovements. ILoss Iof Ithe Iability Ito Ijudge Iand Icontrol Idistance, Ispeed, Iand Ipower Iof Ia Imotor Iact Iis Itermed Idysmetria. ISince Iwalking Irequires Iproper Ifunctioning Iof Ithe Icerebellum Iand Imotor, Isensory, Iand Ivestibular Isystems Ias Iwell Ias Ia Iwhole Ihost Iof Ireflexes, Iassessment Iof Igait Ican Iprovide Iimportant Iinformation Ito Iguide Ithe Ifocus Iof Ithe Irest Iof Ithe Ineurological Iexam. IIt Iis Ifor Ithis Ireason Ithat Imany Iphysicians Ilike Ito Iwatch Ithe Ipatient Iwalk Iat Ithe Ivery Ibeginning Iof Ithe Iexam. IThe Ispecific Iaspects Iof Igait Ifor Iyou Ito Ipay Iattention Ito Iinclude Ibody Iand Iextremity Iposture; Ilength, Ispeed, Iand Irhythm Iof Isteps; Ibase Iof Igait I(how Ifar Iapart Iare Ithe Ilegs); Iarm Iswing; Isteadiness; Iand Iturning. ITesting Itandem Igait I(walking Iheel Ito Itoe) Ican Ibe Ihelpful, Ithough Imany Iotherwise Inormal Ielderly 31 patients Icannot Iperform Ithe Itask. IThe Iscreening Iexam Imust Iinclude Ian Iassessment Iof Igait. Approach Ithe Iexam Isystematically Iand Iestablish Ia Iroutine Iso Ias Inot Ito Ileave Ianything Iout. During Ithe Icourse Iof Ithe Iexam Iit Iis Iimportant Ito Ilook Ifor Ithe Idistribution Iof Iabnormalities I(e.g., Iproximal Ivs. Idistal, Iarms Ivs. Ilegs, Ileft Ivs. Iright). IFor Isensory Itesting Iin Iparticular, Iit Iis Iimportant Ito Ilet Ipatients Iknow Iwhat Iyou Iare Igoing Ito Ido Iand Iwhat Iyou Iexpect Iof Ithem. Perform Ia Iscreening Ineuro Iexam Iin Iall Ipatients, Ieven Ithose Iw/o Ineuro Icomplaints, Ithat Iis Isufficient Ifor Idetection Iof Isignificant Ineurologic Idisease. The Iessential Iscreening Ineurological Iexam Ifor Iadults Iand Iolder Ichildren Mental Istatus I(tested Ithrough Ihistory Itaking). Observation Iof Ieyes, Iface, Ivoice, Iand Icoordination Iduring Ihistory Itaking Iand Ias Ipatient Imoves Iabout Ithe exam Iroom. ILook Ifor Iextraneous Imovements. Gait Iincluding Iarising Ifrom Ichair Iwithout Ihands, Iwalking Ion Itoes, Iheels, Iand Iheel Ito Itoe I(tandem). Visual Ifields. Fine Ifinger Imovements Iand Itoe Itapping. Reflexes Iankles I(may Ineed Ito Icompare Ito Ipatellar), Iplantar. Sensation: Ivibration Iin Itoes; Ipinprick Iin Ifeet; IRomberg Ior Iproprioception Iin Ifeet. IThe Iessential Iscreening Ineurological Iexam Ifor Iyoung Ichildren Mental Istatus I(tested Ithrough Iobservation Iand Iwith Ispecific Iquestions Ifor Ilanguage Idevelopment). 32 Observation Iof Ieyes, Iface, Ivoice, Ilimb Imovement, Iand Icoordination Iduring Ihistory Itaking Iand as Ipatient Imoves Iabout Iin Ithe Iparent's Ilap Ior Ion Ithe Iexam Itable. ILook Ifor Iextraneous Imovements. Gait Iincluding Iwalking Iand Irunning; Itandem Igait Iand Iskipping, Iif Ipossible. IHead Icircumference; Ipalpate Ifontanels Iin Iinfants. Vision/eye Imovements Itracking Iobject, Ilook Ifor Istrabismus I(misalignment Iof Ithe Ieyes). IHearing. Coordination I manipulate Ian Iobject, Ithrow Iand Icatch Ia Iball. Tone I(ventral Isuspension Iand Iresistance Ito Ipassive Imovement) Iin Iinfants. IPrimitive Ireflexes I(Moro, Irooting, Iplacing) Iin Iinfants. Your Iobservation Iof Ithe Iyoung Ichild Ishould Iinclude Ia Inote Iof Iwhether Ithe Ichild Iis Iable Ito Isit Istill Iand Ipay Iattention. IMake Isure Iall Ilimbs Iare Ibeing Iused Iequally. IPre-school Ichildren Ishould Ibe Iasked Iage Iappropriate Iquestions Ito Iassess Ilanguage Idevelopment. IAsk Ithem Ito Iname Iobjects Iand Icolors Iand Iensure Ithat Ithey Ican Icomprehend Isimple Itasks I(without Inonverbal Icues). IHead Icircumference Ishould Ibe Imeasured Iin Iall Iyoung Ichildren Iand Iplotted Ion Ia Ichart. INote Iif Ihead Ishape Iis Inormal. IFontanels Ishould Ibe Ipalpated Iin Iinfants. I(The Ianterior Ifontanel Icloses Ibetween Iabout I7 Iand I19 Imonths; Ithe Iposterior Ifontanel Imay Ibe Iclosed Iat Ibirth.) IVision Iis Itested Iin Iyoung Ichildren Iby Iverifying Ithat Ithey Ifollow Ia Ismall Iobject Imoved Iacross Itheir Ivisual Ifield. IHearing Iis Itested Iby Ilooking Ifor Ia Ibehavioral Iresponse Ito Ia Iloud Isound. II Iomitted Ireflexes Ias Iessential Iin Ithe Iexamination Iof Inormal Iyoung Ichildren, Ibut Inote Ithe Isame Icaveat Ias Iabove: Iparents Imay Ifeel Ideprived Iif Iyou Iomit Ithis Itest. IIf Iyou Iopt Ito Icheck Ithe Iplantar Ireflex, Ibe Iaware Ithat Iit Ichanges Iover Ithe Ifirst Iyear Iof Ilife. IAlmost Iall Imainstream Iclinicians Ibelieve Ithat Ithe Inormal Iplantar Iresponse Iin Iinfants Iis Iextensor. ITest Itone Iin Iinfants Iby Iassessing Ifor Iresistance Ito Ipassive Imovement Iand Iholding Ithe Iinfant Iin Iventral Isuspension. IHealthy Inewborns Iand Iyoung Iinfants Ihave Ia Inumber Iof Ireflexes Ithat Ibecome Iinhibited Iwhen Ithe Icerebral Icortex Imatures. IThese Ishould Ibe Itested Ibecause Itheir Iabsence Isuggests Iglobal Iinjury Iand Itheir Ipersistence Ibeyond Ithe Inewborn Iperiod Isuggests Ilack Iof Inormal Ibrain Imaturation. IThe IMoro Ireflex Iis Isymmetric Iabduction Ifollowed Iby Iadduction Iof Iboth Iarms Ielicited Iby 35 but Ido Inot Inecessarily Iinclude Ithe Ientire Icortex. IIn Igeneralized Iseizures Ithe Ilocation Iand Ilateralization Iare Inot Iconsistent Ifrom Ione Iseizure Ito Ianother. I They Ican Ibe Iasymmetric. They Iusually Ibegin Iwith Ibody Imovements, Iimpaired Iconsciousness, Ior Iboth. If Ionset Iof Itonic-clonic Iseizures Ibegins Iafter Iage I30 Iyears, Isuspect Ia Ipartial Iseizure Ithat Ihas Ibecome Igeneralized Ior Ia Igeneralized Iseizure Icaused Iby Ia Itoxic Ior Imetabolic Idisorder. Types Iof IGeneralized ISeizures Iinclude: Tonic-clonic Iseizure-patient Iloses Iconsciousness Isuddenly, Isometimes Iwith Ia Icry, Ibody Istiffens Iinto Itonic Iextensor Irigidity. IBreathing Istops, Iand Ipatient Ibecomes Icyanotic. IA Iclonic Iphase Iof Irhythmic Imuscular Icontraction Ifollows. IBreathing Iresumes Iand Iis Ioften Inoisy Iwith Iexcessive Isalivation. I njury, Itongue Ibiting, Iand Iurinary Iincontinence Imay Ioccur. Absence Iseizure- IA Isudden Ibrief Ilapse Iof Iconsciousness, Iwith Imomentary Iblinking, Istaring, Ior Imovements Iof Ithe Ilips Iand Ihands Ibut Ino Ifalling. I 2 Itypes Iare Iseen: I Typical: Ilasts I<10 Isecs Iand Istops Iabruptly, IAtypical: Ilasts I>10 Isecs. Myoclonic Iseizures- Isudden, Ibrief, Irapid Ijerks, Iinvolving Ithe Itrunk Ior Ilimbs. IAssociated Iwith Ia Ivariety Iof Idisorders. Myoclonic IAtonic-Sudden Iloss Iof Iconsciousness Iwith Ifalling Ibut Ino Imovements. I njury Ican Ioccur. Pseudoseizures- Imimics Iseizures Ibut Iare Idue Ito Iconversion Idisorders. IDo Inot Iusually Ifollow Ia Ineuroanatomic Ipattern. Cranial INerves I12 Icranial Inerves I- Olfactory-sense Iof Ismell To Itest: Ipresent Ifamiliar Ismell Ithat Iis Inon Iirritating Iwith Ieyes Iopen Iand Icompressing Ieach Inare Ithen Ihave Ithem Iclose Itheir Ieyes Iand Itest Ieach Inostril, Iby Icompressing Ieach Inare Iwith Idifferent Ismells Ithan Ithe Ifamiliar Loss Iof Ismell Ican Ioccur Iin Isinus Iconditions, Ihead Itrauma, Ismoking, Inormal Iaging, IParkinson’s Idisease, Iand Icocaine Iuse II- Optic-Vision To Itest Ivisual Iacuity: Ihave Ithe Ipatient Istand I20 Ifeet Ifrom ISnellen Ieye Ichart, Iif Ithey Iwear Iglasses Ifor Iother Ithan Ireading Ithey Ishould Ibe Iwearing Ithem, Icover Ione Ieye Iwith Ia Icard Iand Inot Ifingers Ito Iprevent Ibeing Iable Ito Isee Ithrough Ithe Ifingers Iand Ihave Ithem Iread Ithe 36 smallest Iline Ithey Ican-the Ivision Iis Iplaced Iin Ia I2 Inumber Iseries Isuch Ias I20/50, Ithe Ifirst Inumber Iindicates Ithe Idistance Iof Ithe Ipatient Ifrom Ithe Ichart Iand Ithe Isecond Inumber Iis Ithe Idistance Iat Iwhich Ia Inormal Ieye Ican Isee Ithe Isame Iline To Itest Ipupils: Iwill Itest Ireaction Ito Ilight-dilation Iand Iconstriction Iusing Ia Ipen Ilight Look Iinto Ithe Ipupil Ito Ilook Iat Ithe Ifundi Ifor Ichanges Iin Iarteries, Ipapilledema, Ipallor, Icup Ienlargement III- Oculomotor-pupil Iconstriction, Iopening Ithe Ieyelid I(elevation), Imost Iextraocular Imovements IV- Trochlear-downward Iand Iinternal Irotation Iof Ithe Ieye IV-Trigeminal Motor Ifunction: Ijaw Iclenching, Ilateral Ijaw Imovement ISensory Ifunction: Ithis Inerve Ihas I3 Idivisions IOphthalmic Maxillary IMandibula r To Itest: Ihave Ithe Ipatient Ito Iclench Iteeth Iand Inote Ithe Istrength Iand Ithen Ihave Ithem Imove Ijaw Iside Ito Iside Will Itest Ithe Isensory Iportion Itest Isharp Iand Isoft Ifeeling Iat Ithe Idifferent Iareas Iof Ithe Iface Iand Iforehead VI- Abducens-lateral Ideviation Iof Ithe Ieye Testing Iof I II, I V, Iand IVI Iwith Ieye Imovement Iyou Ihave Ithe Ipatient Ifollow Iyour Ifinger Iin Ithe I6 Icardinal Idirections Ilooking Ifor Iasymmetric Imovement VII- Facial Motor: Ifacial Imovements Iincluding Iexpressions, Iclosing Ithe Ieye, Iand Iclosing Imouth ISensory-taste Iof Isalty, Isweet, Isour Iand Ibitter Ion Ianterior I⅔ Iof Itongue Iand Isensation Ifrom Ithe Iear To Itest: Inoting Iasymmetry Iin Ifacial Iexpressions, Iwrinkle Iforehead, Iclose Ieyes Iso Iyou Ican’t Iopen, Itense Ineck Imuscles, Ipuff Iout Icheeks VIII- Acoustic-Hearing I(cochlear Idivision) IBalance I(vestibular) ITo Itest: Iwhispered Ivoice Itest Conductive Iloss: Iair Ithrough Iear Itransmission Iimpairment ISensorineural: Idamage Ito Ithe Icochlear Ibranch Weber Itest Iat Ithe Itop Iof Ithe Ihead Iwith Ia Ituning Ifork IRenee Itest: Itest Iat Ithe Iback Iof Ithe Ihead IX- Glossopharyngeal IMotor: Ipharynx Sensory:posterior Iportions Iof Ithe Ieardrum Iand Icanal, Ipharynx, Iposterior Itongue Itaste 37 X-Vagus Motor: Ipalate, Ipharynx, Iand Ilarynx ISensory-pharynx Iand Ilarynx To Itest I X Iand IV Ihave Ithe Ipatient Isay Iahhh Iand Iobserve Ithe Isoft Ipalate Irise Iand Ifall Ias Iwell Ias Ithe Iuvula Iremaining Icentered Iand Ithe Ipharynx Imoving Ilaterally Ilike Ia Icurtain-all Iof Ithis Ishould Ibe Isimultaneous Iand Isymmetrical Test Ithe Igag Ireflex IXI-Spinal IAccessory: Motor: Ithe Isternocleidomastoid Iand Ithe Iupper Itrapezius ISensory: Inone To Itest Imotor: Ifrom Ibehind Iask Ipatient Ito Ishrug Ishoulders Iagainst Ihands Inoting Istrength Iof Ithe Ishrug; Ifrom Iin Ifront Iof Ithe Ipatient Ihave Ithem Iturn Itheir Ichin Iinto Iyour Ihand Inoting Istrength Iand Iobserving Ithe Icontraction Iof Ithe Iopposite Iside Iof Ithe Isterno Imuscle XII-Hypoglossal IMotor: Itongue To Itest Ilisten Ito Ithe Ipatient Iarticulation Iof Iwords, Ilook Ifor Iasymmetry Iof Imovement Iof Itongue Ifrom Italking Iand Ithen Isticking Iout Ithe Itongue Iand Imoving Iside Ito Iside ISensory: Inone Intracranial IPressure Causes Iof Iincreased Iintracranial Ipressure I(ICP): Increase Iin Ibrain Ivolume Generalized Iswelling Iof Ithe Ibrain Ior Icerebral Iedema Ifrom Ia Ivariety Iof Icauses Isuch Ias Itrauma, Iischemia, Ihyperammonemia, Iuremic Iencephalopathy, Iand Ihyponatremia Mass Ieffect ● Hematoma ITumor Abscess IBlood Iclots Increase Iin Icerebrospinal Ifluid ● Increased Iproduction Iof ICSF