Physical Assessment. Class 1

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Andra George
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1 Physical Assessment Class 1

2 Objectives Class 1: Objectives: Review Syllabus and Class Goals and Format At the end of the class, the student will be able to: Understand the components and functions of the nervous system Describe the lobes of the brain and three components of the brain stem, as well as their vascular supply Know the functions of each cranial nerve Assess patient s mental state, perform a MMSE Define and chart specific psychiatric conditions

3 Nervous system functions Rapid Communication Sensory input Integration of sensory input into homeostatic control and decisions Motor output Reflexes Higher brain functions, homeostasis, integration and coordination with other systems (endocrine, muscular, etc.)

4 Nervous system

6 Note: Be sure you understand the conceptual outline in the previous 2 slides. You can orient testing procedures to figure out where a lesion/problem is in the PNS or CNS of a patient.

7 CNS Brain: 1. Cerebrum: higher brain functions 2. Cerebellum: neuromuscular coordination and proprioception 3. Brainstem 4. Diencephalon: thalamus, hypothalamus, epithalamus Spinal Cord

8 CNS: Brain-Cerebrum Frontal Lobes The frontal lobes are important for attention, executive function, motivation, and behavior. Tests for frontal lobe function include working memory (digit span, spelling backward), judgment, fund of knowledge, task organization and set generation such as naming lists of things in a certain category.

9 CNS: Brain-Cerebrum Temporal Lobes The temporal lobes are important for emotional response (amygdala and its connections to the hypothalamus and frontal lobes) and memory (hippocampus and limbic connections). Clinically the main tests for temporal lobe function are those of memory, particularly declarative memory.

10 CNS: Brain-Cerebrum Language- Temporal and Frontal Lobes The principle area for receptive language is Wernicke's area, which is located in the posterior part of the superior temporal gyrus of the dominant temporal lobe. The major region for expressive language is Broca's area located in posterior part of the inferior frontal gyrus of the dominant hemisphere. Homologous regions of the non-dominant hemisphere are important for the non-verbal contextual and emotional aspects as well as the prosody (rhythm) of language. Tests for written and spoken receptive and expressive language are used to "view" these language centers.

11 CNS: Brain-Cerebrum Parietal Lobes The parietal lobes are important for perception and interpretation of sensory information especially somatosensory information. The non-dominant parietal lobe is particularly important for visual-spatial function. The dominant parietal lobe is important for praxis, which is the formation of the idea of a complex purposeful motor act while the frontal lobes are important for the execution of the act. Clinical tests for parietal lobe function include tests for agnosia (such as inability to identify objects by tactile exploration), apraxia (inability to perform purposeful motor acts on command), constructional apraxia (inability to draw objects which require use of visual spatial organization).

12 CNS: Brain-Cerebrum Occipital Lobes The occipital lobes are important for perception of visual information. Areas in the inferior temporal visual association cortex are important for recognition of color and shape as well as the recognition of faces. Projections from the occipital lobe to the superior temporal-parietal area are important for perceiving motion of objects. Tests that are used to examine the occipital lobes and its connections include visual fields (see Cranial Nerve 2), naming of objects, naming of colors and recognition of faces.

13 Evaluating the cerebrum Orientation, Memory Asking questions about month, date, day of week and place tests orientation, which involves not only memory but also attention and language. Three-word recall tests recent memory for which the temporal lobe is important. Remote memory tasks such as naming Presidents, tests not only the temporal lobes but also heteromodal association cortices.

14 Evaluating the cerebrum Attention-working memory Digit span, spelling backwards and naming months of the year backward test attention and working memory which are frontal lobe functions.

15 Evaluating the cerebrum Judgement-abstract reasoning These frontal lobe functions can be tested by using problem solving, verbal similarities and proverbs What would you do if you saw a house on fire? How are an apple and orange similar? What is the meaning of a bird in hand is worth two in the bush?

16 Evaluating the cerebrum Set generation This is a test of verbal fluency and the ability to generate a set of items which are frontal lobe functions. Most individuals can give 10 or more words in a minute. Give me as many words (not Proper or capital) that start with the letter M

17 Evaluating the cerebrum Receptive language Asking the patient to follow commands demonstrates that they understand the meaning of what they have heard or read. It is important to test reception of both spoken and written language.

18 Evaluating the cerebrum Expressive language In assessing expressive language it is important to note fluency and correctness of content and grammar. This can be accomplished by tasks that require spontaneous speech and writing, naming objects, repetition of sentences, and reading comprehension.

19 Evaluating the cerebrum Praxis The patient is asked to perform skilled motor tasks without any nonverbal prompting. Skills tested for should involve the face then the limbs. In order to test for praxis the patient must have normal comprehension and intact voluntary movement. Apraxia is typically seen in lesions of the dominant inferior parietal lobe. Wink Pretend to suck on a straw Pretend to drink from a cup

20 Evaluating the cerebrum Gnosis Gnosis is the ability to recognize objects perceived by the senses especially somatosensory sensation. Having the patient (with their eyes closed) identify objects placed in their hand (stereognosis) and numbers written on their hand (graphesthesia) tests parietal lobe sensory perception.

21 Evaluating the cerebrum Dominant parietal lobe function Tests for dominant inferior parietal lobe function includes right-left orientation, naming fingers, and calculations. Touch left little finger to right elbow Identify the right index finger Serial sevens

22 Evaluating the cerebrum Non-dominant parietal lobe function The non-dominant parietal lobe is important for visual spatial sensory tasks such as attending to the contralateral side of the body and space as well as constructional tasks such as drawing a face, clock or geometric figures. Draw a face, clock Copy a geometric design

23 Evaluating the cerebrum Visual recognition Recognition of colors and faces tests visual association cortex

24 Brainstem Midbrain Pons Medulla Oblongata

25 Brainstem Midbrain -information relay from vision and auditory pathways and involved in visual and auditory reflexes (loud noises cause you to blink, and turn your head) functions: 1. Contains ascending (Sensory)and descending (motor) tracts 2. eye reflexes (for visual tracking of objects/horizon) 3. Contains the nuclei for cranial nerves III and IV

26 Brainstem Pons 1. Contains ascending and descending tracts 2. contains nuclei for cranial nerves V, VI, VII, and VIII 3. visceral reflex centers, including nuclei related to: sleep, hearing, equilibrium, taste, eye movements, facial expression, facial sensation, respiration, swallowing, bladder control, and posture

27 Brainstem Medulla Oblongata 1. Contains ascending and descending tracts 2. decussating(crossing sides of body) of motor tracts at pyramids 3. Contains the nuclei for cranial nerves IX, X, XI, XII 4. Centers for vasomotor (blood pressure), heart rate and contractility, and respiration are located here

28 Connection to Spinal Cord Clinically, there are 2 major somatosensory pathways that are examined. The first is the spinothalamic (ST) and the second is the dorsal column-medial lemniscus (DCML) system. The principle sensory modalities for the ST system are pain and temperature. The principle sensory modalities for DCML system are vibratory, position sense and discriminatory or integrative sensation.

29 Sensory: Spinothalamic Tract (Pain and Temperature)

31 Dorsal Column

33 Blood Supply Arterial Supply 1. Vertebral artery (flows from the subcalvian artery through the C6-C1 transverse foramina and then through the foramen magnum of the occiput where it then becomes the basillar artery inside the cranial cavity where it blends with the Circle of Willis) 2. Internal Carotid arteries (flows from the Common Carotid artery and then through the Carotid Canal of the temporal bone into the cranial cavity where it blends with the Circle of Willis)

36 Circle of Willis

38 Venous Drainage: Internal (#5) & External (#6) Jugular Veins drain to the Subcalvian Vein(#7)

39 Perform a Mini Mental State Exam on a classmate! (And find out if they are losing their mind!!) Use the forms handed out in class and object with you to perform the testing (25 minutes)

40 Common Psychiatric Disease Mood disorders Speech Disorders Anxiety Disorders Psychotic Disorders Organic Brain Disorders (Stroke, infarct, etc.)

41 Mood disorders Depression Manic episodes/ Manic Depression (read book on this)

42 Mood disorders Depression: Depression is a common mental disorder that presents with depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration. These problems can become chronic or recurrent and lead to substantial impairments in an individual's ability to take care of his or her everyday responsibilities. At its worst, depression can lead to suicide, a tragic fatality associated with the loss of about thousand lives every year.

43 Mood disorders Suicide: is defined as the intentional taking of one's own life. Prior to the late nineteenth century, suicide was legally defined as a criminal act in most Western countries. In the social climate of the early 2000s, however, suicidal behavior is most commonly regarded and responded to as a psychiatric emergency.

44 Disorders of Speech Aphonia/dysphonia: a loss or impairment of voice from disease of larynx or its nerve supply Dysarthria: defective muscular control of the lips, tongue, palate, or pharynx causing altered speech. Caused by motor lesion in CNS or PNS, parkinsonism, or cerebellar disease Aphasia: dominant cerebral hemishere problems related to understanding or producing language

45 Common Psychiatric Disease Dementia: Dementia is a loss of mental ability severe enough to interfere with normal activities of daily living, lasting more than six months, not present since birth, and not associated with a loss or alteration of consciousness.

46 Common Psychiatric Disease Dementia (2) Dementia is a group of symptoms caused by gradual death of brain cells. The loss of cognitive abilities that occurs with dementia leads to impairments in memory, reasoning, planning, and personality. While the overwhelming number of people with dementia are elderly, it is not an inevitable part of aging. Instead, dementia is caused by specific brain diseases. Alzheimer s Disease (AD) is the most common cause, followed by vascular or multiinfarct dementia. Family history of Dementia puts you at a 3x greater risk for developing it.

47 Anxiety Disorders Panic Disorders: To have a diagnosis of panic disorder, you must also have experienced recurrent unexpected panic attacks. These are panic attacks that occur "out of the blue," not triggered by anything in your environment.

48 Anxiety Disorders Panic Disorders (2):Symptoms pounding heart or increased heart rate sweating trembling or shaking feeling as though you are being smothered or having trouble breathing choking chest pain/discomfort nausea or abdominal pains and/or discomfort feeling dizzy, lightheaded, or faint feeling as though things around you are unreal or feeling detached from yourself feeling like you are going to lose control or go crazy fear of dying numbness or tingling in extremities chills or hot flashes

49 AGGGHHHH!!!

50 Anxiety Disorders Obsessive-Compulsive: obsessions or compulsions that cause anxiety or distress, often time consuming Acute Stress: often following a traumatic event a person may develop Posttraumatic Stress Disorder Generalized Anxiety: restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, poor sleep quality or ability

51 Psychotic Disorders Schizophrenia Delusional Disorder Psychotic disorders

52 Other Brain Disease Cerebrovascular Accident (Stroke): signs The symptoms of stroke are distinct because they happen quickly: Sudden numbness or weakness of the face, arm, or leg (especially on one side of the body) Sudden confusion, trouble speaking or understanding speech Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden severe headache with no known cause

53 Other Brain Disease Cerebrovascular Accident (Stroke): risk factors High blood pressure Heart disease Smoking Diabetes High cholesterol

54 Cranial Nerves: Review! Review the Cranial Nerves general functions for next class. We will start doing physical examinations of the cranial nerves next class and you will be expected to know some general functions of the nerves.

Inside Your Patient s Brain Michelle Peterson, APRN, CNP Centracare Stroke and Vascular Neurology

Inside Your Patient s Brain Michelle Peterson, APRN, CNP Centracare Stroke and Vascular Neurology Activity Everyone stand up, raise your right hand, tell your neighbors your name 1 What part of the brain