Assessment3

• Behavioral changes: memory loss, inappropriate social behaviors
• aphasia: language impairment due to brain injury
• brain lesions: stroke/CVA, trauma, tumor
• symptoms of mental illness

• Posture
• - normal: straight, erected, relaxed
• -abnormal: pacing, tensed muscles= anxiety, hunched over = depressed
• Body movement
• - normal: coordinated, smooth & even
• - abnormal: restless, fidgety = anxiety, or slow= depression
• - cogwheel = parkinsons
• dress/ grooming & hygiene
• -norm: appropriate for season, clean, shaven
• -abnormal: disheveled, dirty, not shaven-
• unilateral neglect- depression/ mental status

• Level of Consciousness
• Speech: smooth, articulated, appropriate volume/ fast = anxiety, slow = depressed, distorted = stroke
• Affect&mood: relaxed & cooperative " how do you feel today,
• - flat, no expression = mental illness
• - schizophrenia: mood swings, bizarre moods

• Orientation: Person, place & time
• Recent memory:
• Remote memory:
• New learning: 4 unrelated words & repeat them back

• tell them 3 random words
• ask them to draw a clock at a certain time
• then ask them to repeat the words again
• 1-2 words = possible dementia
• no words = dementia
• abnormal clock = cognitive impairment

• normal: logical
• abnormal: illogical
• - obsession - repetitive thoughts
• - compulsion - repetitive behavior

• They exhibit:
• sadness, grief, despair, hopelessness
• Ask:
• have you ever thought of harming yourself?
• are you thinking about it right now?
• do you have plans?

• If pt. shows 5 or more symptoms for 2wks:
• depressed
• fatigued
• wt loss
• agitation
• worthlessness
• diminished interest
• inability to think
• insomnia/ hypersomnia
• death

• response time = slower
• recent memory may decrease
• Same: intellect & remote memory

• headache
• headinjury
• dizziness/vertigo
• syncope (random fainting)
• seizures
• tremors
• incoordination
• stroke/ CVA
• meningitis
• dysphagia
• dysphasia
• dysarthria
• aphasia

Olfactory: close eyes & test each nostril separately

Optic: visual acuity, snellen chart

• muscles around the eye, tested together
• PERRLA = III
• Extraoccular movements/ cardinal field of gaze test

Nystagmus: jerking of the eye

Ptosis: droopy eyelid on one side

• Trigeminal nerve: opthalmic, maxillary, mandibular
• sensory: light touch
• corneal reflex: cotton swab ( involuntary blinking)
• motor: masticatoin

• Facial:
• motor: symmetry of movements & strength
• sensory: taste sweet, salt & sour (uncommon test)

asymmetry of the face, cranial nerve VII impairment

• Acoustic: hearing acuity
• Whisper test:

• Glossopharyngeal & vagus
• motor: tongue blade, test pharynx movement
• uvula, soft palate, gag reflex

• Spinal acessory nerve:
• sternomastoid & trapezius muscle; turn head & shrug shoulder against resistance

Hypoglossal: tongue stick out

• Tandem walking: heel to toe(soberity)
• Romberg: stand stil, test balance (positive = fall)
• shallow knee bed/ hop in place
• rapid alternating movements
• finger to finger
• finger to nose
• heel to shin

• Graded 0-4: 0 = none 2= normal 4= clonus
•  Reinforcement: raise hand up to relax other muscles
• clonus: short, jerking motion on stimuli

• Eyes: 4
• Verbal: 5
• Motor: 6
• max score = 15
• 7 or < = coma

• eyes need to closed
• pain: sharp/ dull
• light touch: hyperthesia =lots of sensation!
• vibration: low pitched tuning fork
• mono-filament: can't feel = peripheral neuropathy
• proprioception/ position sense/ kinethesia
• sterognosis: object in palm & they tell you what it is
• graphethesia

• Headaches
• Head injuries did they loose LOC
• dizziness
• neck pain
• lumps & swelling

• normocephalic
• microcephalic
• macrocephalic
• symmetrical

• symmetry of muscles
• range of motion
• lymph nodes - advanced technique
• trachea @ midline
• thyroid - advanced technique

children and infants have bigger heads compared to body size= more prone to head injury

• normal: <1cm & nonpalpable
• lymphadenopathy: >1cm/ infection, allergies or cancer
• Infection: enlarged, painful, tender, warm, movable, maybe bilateral
• Malignant: enlarged, non tender, unilateral, fixed, hard to palpate

• Acromegally: excess growth hormone; pituitary tumor, facial bone over growth
• CVA/stroke: asymmetry, whole body
• Bell's palsy: asymmetry, only affect face
• multiple thyroid nodues
• thyromegaly
• assymmetry

• pain: sudden = 911
• difficulty w/ vision: decreased acuity, blurry, blindspots = tumor, halo = glaucoma
• photophobia
• strabismus (misalignment)
• redness
• swelling
• water discharge = possible infection
• past hx & self care

• snellen chart
• hand held vision screen
• card to cover eye
• pen light
• opthalmoscope

• Snellen chart: stand 20ft away, numerator = distance away, nominator = line read, smaller = better
• E chart: for children & pts that don't know the alphabet

• Near vision test: hold chart 14 inches away, 14/14 if they get it all right
• - presbyopia: when they have to move it farther to read it

Visual fields: right & left eye/ confrontation test. When they cover one eye and something comes from the side, they'll say when they can see it, not very accurate

• Corneal light reflex: when the light reflect in the same spot on both eyes
• cover test: cover 1 eye, pt look forward then take away cover, if covered eye moves into position = muscle weakness
• extraoccular movements/ EOMS/ 6 cardinal fields of gaze

• Strabismus: disparity in eye alignment
• Phoria: mild eye weakness

• Eyebrows: symmetrical
• Eyelids & lashes
• eyeball alignment
• conjunctiva & white sclera
• lacrimal apparatus

• cornea: clear w/ lens underneath
• iris & pupil: flat & round
• -size, shape & eual
• -pupillary light reflext
• -accommodation

• pupils
• equal
• round
• reactive to
• light
• accomodation

• older adults:
• - decreased vision
• -deceased peripheral vision
• - decreased tears, dry eyes
• Arcus senilis: white ring on top of eyes, not medically significant

• exopthalmos: eyes buldges out; b/c Graves disease, hyperthyroidism
• Conjunctivitis: pink eye
• Periorbital edema: w/ renal failure, allergic rx, CHF
• Presbyopia
• Lid lag: hyperthyroidism
• macular degeneration: loss of central vision

• ear aches
• infections
• discharge/ otorrehea
• hearing loss, sudden = refer
• tinnitus; ringing
• vertigo; loss of balance
• hearing & screening protection
• amt of ear wax

• Advanced technique;
• 3yrs or older = pull up & back
• younger = down & back

• Placement & alignment: low set ear might indicate mental illness/ kidney problems
• hearing acuity: whisper test

• conduction: transmission of sound into ear, cause- wax/ otosclerosis
• Sensorineural: defect in inner ear, cause: CN8 impairment, aging, ototoxic drugs, loud noises.

• otoscope last for infants
• presbycusis in older adults
• otitis media, ear infections in children, they might have speech impairment

• nose discharge: color & amt
• colds
• sinus pain
• hx, of nose bleeds (epistaxis)
• allergies
• changes in smell
• sore throat
• bleeding gums
• tooth aches
• hoarseness; how long
• dysphagia
• xerostomia/ decrease saliva
• smoking & alcohol
• altered taste
• self care

• gingivitis
• gingival hyperplasia- dilantin/ pregnancy
• oropharynx
• buccal mucosa- ulcers
• cyanosis of lips

• dry mucosa,
• breathing through mouth
• furrowed tongue
• acute confusion

• I:  see anterior & posterior pillars
• II: see only anterior, covers posterior
• III: touches uvula
• IV: kissing tonsils

• Leukoplakia: cancerous, refer
• cadidiasis/ Thrush
• yeast infection