104 terms

General Survey and Mental Status Examination

General Survey
~A study of the WHOLE person
~Covers GENERAL health state and physical characteristics
~An introduction to the physical exam
Areas to Assess in the General Survey
~Physical Appearance
~Body Structure
Does pt appear stated age (younger, older)

Physical Appearance
Is pt's development appropriate for their GENDER and age?

Physical Appearance
Level of Consciousness

Physical Appearance
Skin Color
Is pt's color tone even, pigmentation consistent with genetic background?
Look for abnormalities:

Physical Appearance
Skin is pale, white tone: shock, anemia, decreased circulation

Skin Color Abnormality
Skin is blueish gray in lips, finger nails, and around the eyes: cardiac or respiratory problems (Decreased circulation)

Skin Color Abnormality
Skin has yellow discoloration: Liver disease

Skin Color Abnormality
Skin has red discoloration: fever, blushing, inflammation, polycythemia, carbon monoxide poisoning

Skin Color Abnormality
Facial Features
Parkinson's Disease
Flat expressionless facial expression

Facial Features
Graves Disease (hyperthyroidism)
Bulging eye balls, very thin (high BMR)

Facial Feature Abnormality
Low BMR, struggle with weight, mixed edema, dry skin and very coarse hair

Facial Feature Abnormality
Stroke (CVA)
Paralysis of facial muscles

Facial Feature Abnormality
Body Structure: Stature
Is pt's height normal for age and heritage?
Achondroplastic Dwarfism
Congenital disorder preventing the convertion of cartilage into the long bones; short arms and legs, prominent forehead

Stature Abnormality
Excessive secretion of growth hormone BEFORE puberty; delays closure of the bones

Stature Abnormality
Excessive secretion of growth hormone AFTER puberty; overgrowth of bones in face, hands, head and feet (not height)

Stature Abnormality
Short Stature
Decrease in growth hormone in childhood below the 3rd percentile

Stature Abnormality
Body Structure: Nutrition
Is pt's weight within normal range
Emaciated; physical "wasting" with malnutrition, loss of weight and muscle mass due to disease

Nutritional Abnormality
Even fat distribution

Nutritional Abnormality
Centripetal Obesity
Obesity concentrated in FACE, NECK and TRUNK with thin legs and arms (Cushing's Disease and long dosage of steroids)

Nutritional Abnormality
Body Structure: Symmetry
The wasting away of a body organ or tissue

Symmetry Abnormality
Abnormal increase of a body part or organ

Symmetry Abnormality
Body Structure: Posture
Is pt comfortably erect? Check plumb line through EAR, SHOULDER, HIP, PATELLA and ANKLE
Body Structure: Position
Is pt comfortable sitting?
Tripod Position
Client leans forward and uses arms to support weight and lift chest to increase breathing capacity; often seen in COPD

Position Abnormality
Upright Position
Sitting straight up; often seen in CHF (Congestive Heart Failure)

Position Abnormality
Fetal Position
Curled up body position that resembles a fetus in the uterus; often seen in abdominal pain

Position Abnormality
Body Structure: Body Build
Arm span = Height
Marfan's Syndrome
Arm span > height; (Abraham Lincoln and Rachmaninoff)

Body Build Abnormality
Mobility: Gait
Smooth, even and balanced?
Leg is stiff and drags in semicircle (CVA); Partial paralysis of the right or left half of the body

Gait Abnormality
Cerebellar Ataxia
Wide based gait, difficulty with turns and uncoordinated movement (tumors with cerebellum, intoxication)

Gait Abnormality
Parkinsonian Gait
Posture is stooped, wth head and neck forward; Pt is slow in getting started. Steps are short and often shuffled.

Gait Abnormality
Steppage or Foot drop
Hallmark sign of untreated syphilis
Mobility: Range of Motion
Does pt have full mobility of each joint? No involuntary movements?
~Check for paralysis (absent movement)
Tics or Tremors
Seen in pt's with nueromuscular disease, Parkinson's disease, alcohol abuse, multiple sclerosis
Behavior: Facial Expression
Are the pt's expressions appropriate and do they maintain eye contact?
Behavior: Mood and affect
Is the pt's comfortable and cooperative?
~Flat affect, depressed, anxious?
~Hostile, distrustful, suspicious?
Behavior: Speech
Does the pt have good articulation? Is language clear and understandable
Impairment in ARTICULATION; problem uttering words (disease of the oral cavity, tongue or pharynx muscles)

Speech Abnormality
Impairment in PRODUCTION and UNDERSTANDING (brain lesion or nuerodevelopmental problem)

Speech Abnormality
Behavior: Dress
Is pt's clothing appropriate to climate? Is the clothing clean?
Behavior: Personal Hygiene
Is the pt clean and groomed? Change in grooming indicates illness, depression, mental illness
Mental Status
Consists of a person's EMOTIONAL and COGNITIVE functioning

Good mental status-> optimal functioning
Mental Disorder
Clinically significant behavior or psychological pattern that is associated with present DISTRESS, DISABILITY and has a significant risk of suffering, death, pain, disability, or loss of freedom
~organic disorder: physical cause (delirium, dementia, intoxication, brain lesions)
~psychiatric mental illness (anxiety disorders)
Pt will have PAINFUL symptomatology
Pt will have IMPAIRED functioning
Mental Disorder
In the physical exam, mental status is inferred thru assessment of BEHAVIOR

~Onset is GRADUAL
~Attention span is normal
~Recent memory is impaired
~Caused by alcoholisms, cerebral anoxia, brain infarcts, many diseases (Alzheimer's)
~Onset is ABRUPT
~WORSE in the PM
~Attention is impaired
~Recent memory is impaired
~ Caused by acute illness, fever, infection, dehydration, electrolyte imbalance, medications and alcoholism
~Onset can be ABRUPT or GRADUAL
~Prognosis is variable
~WORSE in the AM
~Attention span is variable
~Memory can be impaired
~May coincide with life event
Responsible for mental status; 2 hemispheres divided into lobes (Cerebral cortex -> higher mental functioning)
Frontal lobe
Responsible for motor cortex, emotions, short term memory, speech formation (Broca's area)
Parietal lobe
Responsible for processing sensory data and long term memory
Temporal lobe
Responsible for perception and interpretation of sounds (Wernicke's area), comprehension of spoken and written language, long term memory
Limbic System
Responsible for survival behaviors (mating, agression, fear, love) and formation of memories
Components of the Mental Status Exam
Thought processes
Full mental status exam when: 1
Family member is concerned: pt exhibits memory loss and/or inappropriate behavior
Full mental status exam when: 2
Brain lesions: pt has experienced trauma to the head, lesion, s/p CVA
Full mental status exam when: 3
Aphasia: pt has impaired language due to brain damage
Full mental status exam when: 4
Symptoms of psychiatric illness: especially if acute onset
HPI: Disorientation
Onset: Abrupt or Insidious?
Associated Probelms: nuerological problems, brain injury or infection?
Medications: opoids, narcotics, anti-depression agents?
HPI: Depression
Thought or Feellings: hopelessness
Best in AM or PM
Recent cause of grief
Hurting self
HPI: Anxiety
Describe avoidance of situations or people
Traumatic event
Associated symptoms
PMH: Nuerological disorders/Psychiatric therapy or hospitalizations
Brain surgery, brain injury, chronic diseases
FH: Psychiatric disorders
Mental illness or susbtance abuse
FH: Mental retardation
Includes autism
FH: Alzheimer's disease
Genetic link
FH: Learning disorders
ADD runs in families
ROS: Emotional Status
Ask about feelings about oneself, coping strategies
ROS: Cognitive changes
Any problems with communication, memory or thought processes
ROS: Sleeping or eating patterns
Any problems with weight loss or weight gain
ROS: Substance abuse
Use of alcohol or street drugs
Examination of Cognitive Abilities
Signs of Possible Impairment
~Significant memory loss
~Impaired communication
~Inappropriate affect
~Personal care difficulties
~Hazardous behavior
Cognitive Impairment Test
~What year is it now?
~What month is it now?
Memory Phase
~What time is it now?
~Count backwards 20 to 1
~Say the months in reverse order
~Repeat the memory phase

High sensitivity in picking up mild forms of dementia
Mini Mental State Examination
Tool for detecting the PROGRESSION of an organic disease
~11 questions
~Score below 24 indicates probable cognitive impairment
~Score below 17 indicates definite cognitive impairment
Examination: State of Consciousness
Should be oriented to:
Person: Full name
Time: day, week, date
Place: Location
Situation: Why pt is there
A+O X 4

Orientation is 1st lost to time -> place-> situatioin and rarely to person
Note Level of Stimulus
Name called in:
~Normal voice
~ Loud voice
~Light touch on person's arm
~Vigorous shake of shoulder
~Pain applied: pinch below clavicle, pressure on chest, press on fingernail, pinch nipple
Awake or readily aroused, oriented, responds appropriately

Examination: Expected Levels of Consciousness
Drowsy, falls asleep quickly

Examination: Expected Levels of Consciousness
Sleeps most of the time, difficult to arouse, confused when aroused

Examination: Expected Levels of Consciousness
Unconscious, responds only to persistent and vigorous shaking or pain, reflex activity persists

Examination: Unexpected Levels of Consciousness
Completely unconscious, no response to pain, no purposeful movement, some reflex activity to none

Examination: Unexpected Levels of Consciousness
Examination of Cognitive Abilities
~Abstract reasoning (ask pt fable or proverb)
~Arithmetic calculations
~Writing ability (ask pt to write a sentence or draw shape)
~Execution of motor skills (give a simple command)
~Memory (ask pt to repeat a sequence of numbers)
~Attention span (follow a short command)
~Judgement (what would you do if you found a stamped letter)
Examination: Emotional Stability
~Mood and feelings
~Thought process and content (problem with EMOTIONAL disturbances, psychiatric disorders)
~Perceptual distortions and hallucinations (auditory and visual are associated with psychiatric disorders; tactile are associated with alcohol withdrawal)
Examination: Speech and Language Skills
~Voice quality
A disorder of voice VOLUME, quality or pitch due to laryngeal disease

Voice quality abnormality
A defect in articulation due to a MOTOR defect of the lips, tongue, palate or pharynx

Articulation abnormality
Language comprehension and production secondary to BRAIN DAMAGE
Global Aphasia
Speech and comprehension is absent or reduced (most common and severe aphasia; damage to Broca's and Wernicke's)
Broca's Aphasia
Expressive aphasia; Client can understand language but CANNOT EXPRESS himself well; Speech is mostly nouns and verbs or 'telegraphic'
Wernicke's Aphasia
Can hear sounds but CANNOT INTERPRET them; speech is well articulated but has many neologisms; speech is incomprehensible (they can sing)
Pt should follow one to three step directions
Roundabout expression substituting a phrase when cannot think of object's name
Flight of Ideas
Words or sentence which proceeds in a disorderly fashion
Repetition of another person's words
Inventing a new word that has no meaning
Word Salad
Incoherent mixture of words
Additional Assessment Procedures: Glasgow Coma Scale
Used with altered level of consciousness, brain tumor or hypoxic event
~Objective measurment of neurological functioning
~Assess cerebral cortex and brain stem thru verbal response, motor response, eye opening to specific stimuli