PHCL 326
Hadeel Alkofide
April 2011

Its evaluated mainly by two methods :
1.
Inspection
2.
Palpation
Musculoskeletal System

Purpose: Assess function for ability to perform
ADL’s

ADLs: Activities of Daily Living
Inspect for symmetry,
proportion,
muscular
Routine activities
such as &
getting
development
dressed, cleaning the teeth, combing

hair, bathing &
Observe gait, or
& brushing
ability tothe
stand,
sit, rise from
Gait:
feeding oneself
sitting position, & grasp
Theobjects
way a person walks
Musculoskeletal System

Inspect joints for symmetry, swelling,
tenderness, & crepitation

Test muscle strength upper & lower extremities
utilizing opposing force
Crepitation:
Audible or palpable crackling sound
Musculoskeletal System

Palpate large & small joints

Assess range of motion (ROM)

Decreased ROM: Arthritis, fibrosis, tissue
inflammation, & fixed joints

Increased ROM: Increased joint mobility &
joint instability
Musculoskeletal System

Limitation in ROM are expressed in degrees

Palpate joints & surrounding area for
tenderness

Assess for warmth, crepitation, & deformities

Mental status

Cranial nerve function

Sensory & motor function

Reflexes
PHYSICAL
Appearance
Motor Activity
Behavior
EMOTIONAL
Attitude
Mood & Affect
COGNITIVE
Orientation
Attention & Concentration
Memory
Speech & Language
Thought (Form & Content)
Perception
Insight & Judgment
Intelligence & Abstraction
Mental Status

A summary of the physical presentation

Dress, facial expression

Posture, eye contact

Hygiene & Grooming
 “Disheveled”- ruffled appearance
 “Unkempt”- poor attention to grooming


Body habits, nourishment status
General description of body type/ build, & nutritional
status
Mental Status
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
Quality & the types of actions observed
Reduction in the level of movement (psychomotor
retardation)

Slowed movement (bradykinesia)

Decreased movement (hypokinesia)

Absence of movement (akinesia)


Increases in the overall level of movement
(psychomotor agitation)
Tremor
Mental Status

Range & Frequency of Spontaneous Movements

Psychomotor activity

Abnormal movements

Psychomotor refers to movements that appear driven
from within, by one’s internal emotions at the time

Psychomotor Agitation, vs.

Psychomotor Retardation
Mental Status


Abnormal Movements
Automatisms- “automatic” involuntary movements;
form of seizure


Ex. Lip-smacking, eye-blinking, staring
Mannerisms: goal-directed, complex behaviors carried
out in an odd way or inappropriate context
Mental Status

Patients may be:

Open, friendly, cooperative, willing, & responsive

Closed, guarded, hostile, suspicious & passive

Describe responses to questions, expression, posture,
eye contact, tone of voice
Mental Status


Affect: an external expression of an emotional state is
potentially observable
Mood: an internal emotional experience that influences
perception of the world & behavioral responses
Mental Status
Mood

Is the patient’s mood appropriate to situation?

Sad, Angry, Depressed, Anxious

Appropriate/Inappropriate
Mental Status
Mood


Descriptors: euphoric, dysphoric, hostile, fearful,
anxious, or suspicious
Stability of mood can also be noted, with the
alternation between extreme emotional states being
referred to as emotional lability
Mental Status
Affect


Range, intensity, & variability of affect can be variously
portrayed:
Restricted (i.e., low intensity or range of emotional
expression)

Flat (i.e., absence of emotional expression)

Exaggerated (i.e., an overly strong emotional reaction)
Mental Status

Alertness

Attention & Cooperation

Orientation

Speech & Vocabulary

Memory

Insight & Judgment

Abstract Thinking

Calculation

Object Recognition

Praxis
Mental Status.. Cognitive
Level of Consciousness – LOC



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Alert: Awake, answers questions
Lethargic: Sleeps when undisturbed, arouses to normal
voice, answers questions appropriately –may be “fuzzy”
Obtunded: Sleeps most of time. Loud shout or vigorous
shake to arouse. Mumbles
Stupor/Semi-coma: Responds only to pain stimuli.
Mumbles, moves restlessly. Withdraws to avoid
pain/noxious stimuli
Coma: Un-responsive to any stimulus
Mental Status.. Cognitive



Test attention by seeing if the patient can remain
focused on a simple task, such as spelling a short word
forward & backward (W-O-R-L-D / D-L-R-O-W is a
standard)
These tests of attention depend on language, memory,
& some logic functions as well
Degree of cooperation should be noted, especially if it
is abnormal, since this will influence many aspects of
the exam
Mental Status.. Cognitive

Person, place, date/time, event

Time is the first to go, person the last.

Normal: Expressed as oriented x3

Disoriented? All parameters or 1 or 2?

Does the patient re-orient?

Is this a change from baseline?
Mental Status.. Cognitive

Have the patient repeat a specific phrase

Note his speech during the whole exam process

Clear, Slurred


Minimal (mostly "yes" and "no" answers, little
volunteered information)
Talkative

Rapid/Pressured (as in possible hypomania or mania)
Mental Status.. Cognitive
Immediate

Say a list of single digit numbers & ask patient to
repeat them
Short term

Have the patient memorize 3 unrelated words & ask
him to repeat them later
Long-term memory

Ask the patient about a known historical event that
happened in his life time
Mental Status.. Cognitive



Insight: a dimension that describes the extent to which
patients are aware that they have a problem
Refers to an awareness of the nature & extent of the
problem, the effects of their problem on others, & how
it is a departure from normal
A strong lack of insight can be an important indicator
of unwillingness to accept treatment
Mental Status.. Cognitive


Judgment: The ability to make sound decisions can be
compromised for a number of reasons
Ascertain if poor decisions are the result of problems in
the cognitive processes involved in the decision
making process, motivational issues, or failures to
execute a planned course of action

Six Tenets of Professionalism:
1.
Altruism
2.
Accountability
3.
Excellence
4.
Duty
5.
Honor and Integrity
6.
Respect for Others
Accountability is the
acknowledgment and assumption
of responsibility for actions,
products, decisions, and policies

Mental status

Cranial nerve function

Sensory & motor function

Reflexes
Neurological Assessment

There are 12 cranial nerves

Please refer to table 4-9 page 93 for assistance
Neurological Assessment
I - OLFACTORY
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

Don’t assess unless patient complains of loss of sense of
smell or patient has a head injury
Don’t use a noxious stimulus
Ask him to close eyes & identify familiar odor one nostril at
a time (Coffee, lemon)
II - OPTIC

Visual acuity

Visual fields

Fundoscopic exam ( eye exam)
Neurological Assessment
III/IV/VI Oculomotor, Trochlear, Abducens

Size, shape of pupils, pupillary response

Eye movements

9 cardinal positions
V - Trigeminal
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Motor - jaw strength: ask patient to clench teeth
Sense – ability to sense sharp, dull, hot cold, over front
half of the face
Neurological Assessment
VII - Facial
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
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Observe for facial asymmetry
Observe facial movements when the patient frowns,
smiles, whistle, puffs out the cheeks & raises eyebrows
Test patient's ability to identify sweet, sour & salty
tastes
VIII – Acoustic

Test hearing
Neurological Assessment
IX/X - Glossopharyngeal, Vagus

Assess quality of speech

Assess gag reflex
XI - Spinal Accessory

Test ability to shrug shoulders & turn the chin from side to
side against resistance
XII - Hypoglossal

Tongue strength (Stick out tongue)

Note abnormalities, asymmetry, deviation or atrophy
Neurological Assessment
Cranial Nerve Function Video
Neurological Assessment
For further assistance
Please visit
http://neuroexam.med.utoronto.ca/
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Mental status
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Cranial nerve function
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Sensory & motor function
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Reflexes
They will not be
covered here