Inspection  Purpose: Assess function for ability to perform ADL’s  Inspect for symmetry, proportion, and muscular development  Observe gait, stance, and ability to stand, sit, rise from sitting position, and grasp objects  Inspect muscle for symmetry  Inspect joints for symmetry, swelling, tenderness, and crepitation  Test muscle strength upper and lower extremities utilizing opposing force

Palpation  Palpate large and small joints  Assess range of motion ROM  Decreased ROM ◦ Arthritis, fibrosis, tissue inflammation, and fixed joints  Increased ROM ◦ Increased joint mobility and joint instability  Limitation in ROM are expressed in degrees  Palpate joints and surronding area for tenderness  Assess for warmth, crepitation, and deformaties

PHYSICAL AppearanceMotor Activity Behavior EMOTIONAL AttitudeMood and Affect COGNITIVE OrientationAttention and Concentration MemorySpeech and Language Thought (Form and Content)Perception Insight and JudgmentIntelligence and Abstraction

Appearance:  A summary of the physical presentation to paint a clear mental portrait ◦ Dress, facial expression, ◦ Posture, eye contact ◦ Hygiene and Grooming –“Disheveled” –“Disheveled”- ruffled appearance –“Unkempt” –“Unkempt”- poor attention to grooming ◦ Body habitus, nourishment status  General description of body type/ build, and nutritional status

Motor Activity:  quality and 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

 Range and Frequency of Spontaneous Movements –Psychomotor –Psychomotor activity ◦ Abnormal movements  Psychomotor  Psychomotor refers to movements that appear driven from within, by one’s internal emotions at the time –Psychomotor Agitation –Psychomotor Agitation, vs. – Psychomotor Retardat ion

 Automatisms- “automatic” involuntary movements; form of seizure ◦ Ex. Lip-smacking, eye-blinking, fumbling with clothing, staring :  Mannerisms: goal-directed, complex behaviors carried out in an odd way or inappropriate context

Behavior ◦ level of consciousness extending from alert through, drowsy, a clouding of consciousness, stupor (lack of reaction to environmental stimuli) and delirium (bewildered, confused, restless, and disoriented), to coma (unconsciousness ◦ degree of arousal (e.g., hypervigilance to environmental cues and hyperarousal such as observed in anxious and manic states) ◦ mannerisms (e.g., tics and compulsions).

Attitude:  Identifiers may be open, ◦ Friendly, Cooperative, willing, and responsive on the hand ◦ Closed, guarded, hostile, suspicious, passive  Describe attentiveness, responses to questions, expression, posture, eye contact, tone of voice

Mood and Affect  Affect (an external expression of an emotional state) is potentially observable  Mood (internal emotional experience that influences perception of the world and behavioral responses)

Mood and Affect  Is the patient’s mood appropriate to situation?  Sad, Angry, Depressed, Anxious  Restricted (reduced), Blunted (greater reduction), Flat (absence or near absence of any affect)  Appropriate/Inappropriate  Labile

Mood and Affect  Descriptors: euphoric, dysphoric, hostile, apprehensive, fearful, anxious, suspicious ◦ Stability of mood can also be noted, with the alternation between extreme emotional states being referred to as emotional lability

Mood and Affect ◦ Range, intensity, and variability of affect can be variously portrayed:  restricted (i.e., low intensity or range of emotional expression)  blunted (i.e., severe declines in range and intensity of emotional range and expression)  flat (i.e., absence of emotional expression,)  exaggerated (i.e., an overly strong emotional reaction) ◦ Appropriateness (expression incongruent with verbal descriptions and behavior) ◦ General responsiveness

Level of Consciousness – LOC  Alert: Awake, answers questions  Lethargic/Somnolent: 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. Speaks in monosyllables, mumbles.  Stupor/Semi-coma: Responds only to vigorous shake or pain. Groans, mumbles, moves restlessly. Withdraws to avoid pain/noxious stimuli  Coma: Un-responsive to an y stimulus

 We test attention by seeing if the patient can remain focused on a simple task, such as spelling a short word forward and backward (W-O-R-L-D / D-L-R-O-W is a standard), repeating a string of integers forward and backward.  Normal digit span is 6 or more forward, and 4 or more backward, depending slightly on age and education.  These tests of attention depend on language, memory, and 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.

 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 client re-orient?  Is this a change from baseline?  Document level of orientation along with descriptive statements supporting abnormal findings.

Have the patient repeat a specific phrase Note his speech during the whole exam process.  Clear, Slurred, Garbled  Minimal (mostly "yes" and "no" answers, little volunteered information)  Talkative ◦ Rapid/Pressured (as in possible hypomania or mania

 Described in terms of: ◦ Rate (e.g., slow, rapid) ◦ Intonation (e.g., monotonous) ◦ Spontaneity ◦ Articulation ◦ Volume ◦ Quantity of information conveyed  mutism (i.e., absence of speech)  poverty of speech (i.e., reduced spontaneous speech)  pressured speech (i.e., rapid speech that is hard to interrupt and understand)  Language includes reading, writing, and comprehension.

 Immediate ◦ Say a list of single digit numbers and ask patient to repeat them  Short term ◦ Have the patient memorize 3 unrelated words and ask him to repeat them later.  Long-term memory ◦ ask the patient about a known historical event that happened in his life time.

 Insight : a dimension that describes the extent to which clients are aware that they have a problem ◦ A strong lack of insight can be an important indicator of unwillingness to accept treatment ◦ Insight refers also to an awareness of the nature and extent of the problem, the effects of their problem on others, and how it is a departure from normal  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

See table 4-9  I - OLFACTORY ◦ 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 and identify familiar odor one nostril at a time (Coffee, lemon)  II - OPTIC ◦ Visual acuity ◦ Visual fields ◦ Fundoscopic exam ( eye exam)

 III/IV/VI Oculmotor, Trochlear, Abducens ◦ Size, shape of pupils, pupillary response ◦ eye movements, accommodation  9 cardinal positions ◦ observe lids for ptosis  V - Trigeminal ◦ motor - jaw strength : ask patient to clench teeth ◦ sens – ability to sense sharp, dull, hot cold, over front half of the face

 VII - FACIAL ◦ Observe for facial asymmetry ◦ Observe facial movments when the patient frowns, smiles, whistle, puffs out the cheeks and raises the eyebrows. ◦ Test patinet’s ability to identifynsweet, sour and salty tastes  VIII – VESTIBULAR ◦ Test hearing

 IX/X - GLOSSOPHARYNGEAL, VAGUS ◦ Assess quality of speech ◦ Assess gag reflex  XI - SPINAL ACCESSORY ◦ Test ability to shrug shoulders and turn the chin from side to side against resistance  XII - HYPOGLOSSAL ◦ tongue strength (Stick out tongue) ◦ Note abnormalities, asymmetry, devitation or atrophy

 STRENGTH ◦ Table 4-10 ◦ Graded ◦ 0 - no movement ◦ 1 - flicker ◦ 2 - movement with gravity removed ◦ 3 - movement against gravity ◦ 4 - movement against resistance ◦ 5 - normal strength

 Upper and lower extremities  Distal and proximal muscles  Subtle weakness ◦ Toe walk, heel walk ◦ Out of chair ◦ Deep knee bend

 Figure 4-16  Assess muscle tone during passive flexion and extension ◦ Increase resistance ◦ Normal ◦ Decreased resistance  Assess abduction, adduction  Assess flexion and extension

 Include walking and turning ◦ Walking on tiptoes/ heels  Examples of abnormal gait ◦ High steppage ◦ Waddling ◦ Hemiparetic ◦ Shuffling ◦ Turns en bloc

 Tremor ◦ Rest ◦ With arms outstretched ◦ Intention  Chorea  Athetosis  Abnormal postures

 Rapid alternating movements ◦ Pronate and supinate of the hand rapidly and repeatdly  Finger to finger to nose testing ◦ Hold finger in front of the patient’s ◦ Ask patient to repeatdly touch his nose and your finger  Heel to shin ◦ Rub the heel on opposite shin  Gait ◦ Tandem

 Stand with feet together – arms extended palms up  assure patient stable - have them close eyes  Romberg is positive if they do worse with eyes closed  Measures ◦ Cerebellar function  Frequently poor balance with eyes open and closed ◦ Proprioception  Frequently do worse with eyes closed ◦ Vestibular system

 GRADED ◦ 0 - ABSENT ◦ 1 - PRESENT WITH REINFORCEMENT ◦ 2 - NORMAL ◦ 3 - ENHANCED ◦ 4 - UNSUSTAINED CLONUS ◦ 5 - SUSTAINED CLONUS

See figure 4-17 Deep Reflexes  Biceps ( C5 and C6)  Brachioradialis ( C5 and C6)  Triceps (C6 and C8)  Knee ( L2 to L4)  Ankle ( S1 and S2)

See figure 4-17 Superficial Reflexes  Abdominal ◦ Stroking each side of the abdomin above the umbilicus ( T8 and T10) and below the umbilicus ( T10 and T12) ◦ The muscle normally tighten  Heel ◦ Stroking the lateral aspect of the sole of the foot from the ehal to the ball with a moderatly sharp object ◦ Normally the toes curl downward

 Table 4-11  Upper motor neuron dysfunction ◦ Babinski  Abnormal plantar reflex  flexor plantar response  Dorsflexion of the great toe and spreading of the other toes ◦ Hofman’s  By dorsiflexing wrist with fingers flexed and flicking the middle finger  Positive : adduction of thumb or index finger

 Table 4-11  Frontal release signs  Normal in infancy, abnormal after ◦ Grasp  Elicit by gently stroking the the palm of the hand between thumb and fingers  Positive: flexion of the fingers ◦ Snout  Elicit by gently tapping face above or below the lips  Positive: puckering of the lips ◦ Suck  Elicit by gently stroking lips from side to center with a tongue depresssor  Positive: sucking movment

 Have patient close eyes  Compare right and left  Start distally and move proximally  Test response to ◦ Vibration ◦ Light touch ◦ pain ◦ Temperature

Response to painful stimulus  Normal  Hypoalgesia  Analgesia  Hyperalgesi a Response to touch  Normal  Hypoesthesia  Anesthesia  Hyperesthesia