Lecture Three: Initial Patient Assessment

Patient History Taking andPatient History Taking andPatient History Taking and Patient History Taking and Neurological Examination for Neurological Examination for

PharmacistsPharmacistsAnas Bahnassi PhD

Anas Bahnassi PhD CDM CDE 2

General History:General History:

History taking and clinical examination form the basis of all clinical assessments. The history enables a short listThe history enables a short list of differential diagnoses to be gene rated. Evidence from clinical examination can beclinical examination can be used to refine this.

3Anas Bahnassi PhD CDM CDE

Steps of Steps of History Taking:History Taking:

f h lHistory of the presenting complaint

Systemic inquirySystemic inquiry

Past medical history

Drug history

Family and social history

Psychiatric historyPsychiatric history

Recording the history

4Anas Bahnassi PhD CDM CDE

History of the presenting complain:

You need to1. Identify your patient.2. Start with open questions:

1 h h d h l fYou need to structure the i i i

1. What happened over the last few days?

2. When was the last time you felt interview in a way that allows you to

ywell?

3. Listen during the first part of the ti d l t ti t t lkextract the relevant

information, while

conversation and let your patient talk.4. Form a differential diagnosis based on

the patient description.,remaining relaxed and polite

p p5. In the second part use closed end

questions to focus on specific points and narrow your differential diagnosisand polite. and narrow your differential diagnosis.



You need to6. Duration and speed of onset of the

patient’s symptoms are particularly You need to structure the i i i

p y p p yimportant.

if f l l i l d f tinterview in a way that allows you to

e.g. if a focal neurological defect develops over the course of a few minutes, this could be due to an acute

extract the relevant information, while

vascular event; if it develops over a number of days there may be infection or demyelization while a,

remaining relaxed and polite

infection or demyelization, while a defect that develops over months could suggest an underlying tumor or and polite. subdural hemorrhage



You need to7. Avoid asking more than one question

at once.You need to structure the i i i

8. Use language that the patient will understand and avoid medical t i linterview in a way

that allows you to terminology.

9. Ask if the patient has any worries or concerns:

extract the relevant information, while Fear and preconceptions often color

the interpretation of symptoms and,remaining relaxed and polite

the interpretation of symptoms and are always important features of the historyand polite.


Systemic inquiry:y q y

A few further

• Cardiovascular : chest pain, palpitations, breathlessness, orthopnoea oedemaA few further

screening questions ffi i

orthopnoea, oedema• Respiratory : breathlessness, cough,

sputum, hemoptysis, chest pain are sufficient to identify any areas

• GI: abdominal pain or swelling, bowel habit and bleeding, vomiting,

• swallowing problemsworthy of additional focus:

swallowing problems • GU: dysuria, frequency, urgency,

hematuria• Neurological symptoms: headache,

weakness or altered sensation, fits, falls and funny turns, change vision,falls and funny turns, change vision, hearing or speech.

• Systemic: anorexic.


Past Medical History:y

Inquire about theDisease Informal LabelA th COPD B hiti hInquire about the

following common ill

Asthma, COPD Bronchitis, emphysemaIschemic Heart Disease AnginaMyocardial Infraction Heart Attackillnesses: Myocardial Infraction Heart AttackCardiac failure Fluid on the lungDiabetes Mellitus Blood sugar

Remember that patients often

gTBSurgery

patients often employ informal

Stroke, epilepsy FitsHypertension Blood pressure

labels: HypercholesterolemiaVenous thromboembolism Clots


Rheumatic feverMajor childhood illness

Drug HistoryDrug History• A t d i l di th ti i f d i i t ti• Accurate doses, including the timing of administration, are

essential, especially for insulin regimes and patients taking warfarin, along with details of the specific formulation taken.If th ti t i l t f di ti k if th h t• If the patient is on a lot of medications, ask if they have an up‐to‐date repeat prescription with them.

• Make specific note of drug allergies. • Ask what the patient means by ‘allergy’:

– Feeling sick or diarrhea is often mislabelled as such. • In patients with lung disease, check if they are prescribed inhalersIn patients with lung disease, check if they are prescribed inhalers

and that they know how to use them. Also ask if they are on long‐term oxygen therapy (marker of disease severity).

• Check if the patient is on long‐term oral theophylline or phenytoin;Check if the patient is on long term oral theophylline or phenytoin; if so, you will need to measure a drug level before prescribing any additional IV treatment.


Family and Social HistoryFamily and Social History

• Social history is often an overlooked component especially for older and disabled patients.I i b t diti ff ti f il b• Inquire about conditions affecting family members.

• Document home circumstances:Li i l h i t t– Living alone, housing type, etc…

• Ask if the patient has family nearby and if they see them. • Determine the patient’s functional capacity and whether• Determine the patient’s functional capacity and whether

they are able to perform the activities of daily living (ADLs), e.g. leaving the house, doing the shopping.(ADLs), e.g. leaving the house, doing the shopping.


Family and Social HistoryFamily and Social History

• Ask about quality of life (QoL). Remember that this should be recorded as the patient describes it, not how you judge it.A k b t ti l d• Ask about recreational drug use.

• Document cigarette use by current and ex‐smokers in pack‐years and alcohol consumption in units per weekyears and alcohol consumption in units per week.– One pack‐year equates to a pack of 20 cigarettes

per day for a year: someone who has smoked 10‐a‐day for 50 years has a 25 pack‐year history.

– One small glass of wine or one 25 mL measure of spirits is roughly equivalent to 1 unit; 1 pint of p g y q ; pordinary strength lager, beer or cider roughly equates to 2 units.Recommended safe limits of alcohol per week for


– Recommended safe limits of alcohol per week for males and females are 21 and 28 units, respectively

Psychiatric HistoryPsychiatric HistoryA d t il d hi t i ti l d t• A detailed history is essential and must include the following:– Educational background, religion and occupation, as these mayEducational background, religion and occupation, as these may

influence interview technique and general approach.– Reason and source of referral (self‐presentation indicates

insight)insight). – Inquire about the patient’s symptoms in their own words,

including their effect upon normal function (e.g. work, family, relationships) date of onset rate of progression and anyrelationships), date of onset, rate of progression and any precipitants identified by the patient.

– Previous treatments, including drugs, surgery and others, e.g. cognitive behavioral therapy electro‐convulsive therapycognitive behavioral therapy, electro‐convulsive therapy

– Suicidal ideation.


Personal HistoryPersonal History• P l hi t h ld i l d• Personal history should include:

– Childhood problems including parental separation and any history of abuse. R l ti hi d it l hi t– Relationships and marital history.

– Work history, including current level of satisfaction at work and reasons for leaving previous jobs.ill l ti iti d hi t f i l– illegal activities and any history of violence

– Premorbid personality, e.g. anxious, obsessive, solitary – Cognitive assessment should be performed (cognitive dysfunction

t i th th f ti l th l )suggests organic rather than functional pathology) – Abbreviated mental test (AMT) score or the mini‐mental state

examination (MMSE). A t (d li i ) d h i (d ti ) iti i i t h ld– Acute (delirium) and chronic (dementia) cognitive impairment should be distinguished by discussion with family members or social contacts.


Abbreviated Mental Test ScoreWh t i ? 1 if tWhat is your age? 1 if correct

What is your date of birth? 1 if correct

Wh t i it? 1 if tWhat year is it? 1 if exact year

What time of day is it? 1 if correct to the next hour

Wh t i thi l ? 1 if t ( f h it l hWhat is this place? 1 if correct (name of hospital or pharmacy area)

Recall a 3 line address 1 if totally recalledRecall a 3 line address 1 if totally recalled

Who is the current Monarch? 1 if correct

What year was world war 2? 1 if correctWhat year was world war 2? 1 if correct

Count backward from 20 to 1 1 if correct with no mistakes

Can you identify these two people? 1 if correct names or correct jobs (dependsCan you identify these two people? 1 if correct names or correct jobs (depends if the patient knows the names or not)


Total score is recorded out of 10A score <7 suggests cognitive dysfunction.

Mini Mental State ExaminationTest Question Max ScoreTest Question Max ScoreTime Day, date, month, season, year 5

Place Country, county, city, building, floor. 5y, y, y, g,

Registration Name 3 objects: “bed, table, book,… ) 3

Attention and C i

Spell ‘world’ backwards or count out five serial 7s 5Concentration

Naming Name 2 objects 2

Recall Ask to recall the 3 objects registered earlier 3Recall Ask to recall the 3 objects registered earlier 3

Repeating Repeat ‘no ifs, ands or buts’: only correct if word perfect 1

3‐Stage task Instruct the patient to (1) take this paper in your right 3hand, (2) fold it in half and (3) drop it on the floor

Reading Write ‘close your eyes’; ask the patient to read and obey

1

Writing Write a sentence: must be complete and grammatically correct

1

Construction Draw interlocking pentagons 1


Construction Draw interlocking pentagons 1

Total score recorded out of 30; <23 suggests cognitive impairment.

Recording the HistoryRecording the History

Many hospitals now provide an admission pack, which includes a history taking proforma for all new admissions. These documents often form part of a unified case record (UCR) or integrated care path a (ICP) While these tools are sef lcase record (UCR) or integrated care pathway (ICP). While these tools are useful, there is a danger that they encourage a highly protocolized, ‘tick‐box’ approach to history taking.

Take time to work beyond the boxes and fully explore what the patient is trying to tell you.

When recording the history of the presenting complaint, include the main problem and mode of f lreferral.

This should be followed by a short paragraph that covers the relevant additional positive or negative points from the history with regard to this presenting


positive or negative points from the history with regard to this presenting problem.

ExaminationExamination• Ensure that the patient’s need for privacy is met.Ensure that the patient s need for privacy is met.• Ask for permission to examine them and check if there is any area that is

sore to touch. • Ensure that the patient is comfortable and in the correct body position• Ensure that the patient is comfortable and in the correct body position

for the system you aim to assess

Supine Position Semi‐recumbent Position

• Cardiovascular and respiratory : 45° semi‐recumbent • Abdominal : lying supine • Neurological : semi‐recumbent position in bed or sitting in chair, depending on th ti l i ti f d


the particular examination performed.

Begin with a general examination, then follow the principles of inspection, palpation, percussion and auscultation as you work through the relevant body systems.Note that when palpating, you should start with the least painful side first and work slowly towards the site of worst pain.

Neurological Assessment:

InspectionpNote any abnormality of resting limb position (contracture or palsy), involuntary movements (seizure activity, tremor and chorea), muscle wasting, fasciculation and gait.Cranial nervesExamine cranial nerves II–XII; Cranial nerve I (olfactory nerve) is notroutinely assessed.


Tests Routinely Performed on Cranial NervesCranial nerve Tests routinely performed

II (Optic) Acuity, pupillary reflexes (ipsi‐ and contralateral), visual fields

III (Oculomotor) Considered together: ocular movements

IV (Trochlear)

VI (Abducent)

V (Trigeminal) Ophthalmic (V 1 ), maxillary (V 2 ) and mandibular (V 3 ) sensory branches; motor function (masseter muscle) rarely tested

VII (Facial) Five sensory branches (raise eyebrows, close eyes tight, show( ) y ( y , y g ,teeth, puff out cheeks and whistle); taste rarely tested.

VIII (Vestibulocochlear) Rarely tested; hearing deficits best assessed by audiometry

IX (Glossopharyngeal) Considered together: gag reflex (IX afferent, X efferent);movement of the soft palate (uvula)

X (Vagus)

XI (Accessory) Shrug shoulders and resist: rotate head to one side againstresistance to test the contralateral sternomastoid muscle


resistance to test the contralateral sternomastoid muscle

XII (Hypoglossal) Ask patient to protrude tongue, look for wasting asymmetry and fasciculation

Cranial Nerve II (and III)• Visual Field

• Pupil assessments– SizeSize

– Shape

– Reaction to light

– Accommodation

• While we are there …– Look for Horner or bilateral

ptosis (Mysathenia)

Cranial Nerve III, IV and VI• Assess eye movement on command

• Ask for diplopia

• Look for nystagmus

Remember the “H”• Remember the H

Cranial Nerve V• Sensory component

– Facial sensation in dermatomes of three trigeminal divisions

– Testing of corneal reflex not expected

• Motor component• Motor component– Jaw reflex

– Masseter muscle

Cranial Nerve VII• Look for facial asymmetry

• Test for muscle power

Cranial Nerve IX and X• Glossopharyngeal nerve:

– Inspect mouth: “Aaaaaaaaaaaaaaaaaaaaah”p• uvula displacement• Asymmetrical rise of velum

• Gag reflex– Sensory component: glossopharyngeal nerve– Motor component: vagal nerve

Cranial Nerve XI• Accessory nerve:

Cranial Nerve XII

• Hypoglossal nerve:L k f d i ti f th t– Look for deviation of the tongue

– Also look for fasciculations of the tongueg


Motor examinationFor motor examination, assess tone, power and reflexes, starting proximally andmoving distally; compare right with left. Give the patient clear instructions whenexamining power. It is important to distinguish between upper and lower motorneurone weakness.

Tone :‘normotonia’ varies; if hypertonia is genuine, check whether

l l d l k f h l dsymmetrical or generalized; look for cog‐wheeling or associated clonus (hard clinical sign if sustained)


ToneTone

• Resistance to Passive Movement• Child should be relaxed (ie distract them withChild should be relaxed (ie distract them with chat)

*Note difference; hypotonia vs. joint flexiblity ff ; yp j f y

• Clonus; ‘rhythmic series of involuntary muscle contraction evoked by stretching the muscle’

↑ Tone↑ Tone

• Spasticity;rapid build‐up of

• Rigidity; sustained resistance

resistance during firstfew degrees of passive

passive movement

movement,

then resistance lessens– Extrapyramidal / Basal ganglia

– Involves a single group of muscles (agonist or

g g

antagonist)

What is the difference between spasticity and rigidity?S i i d i idi 2 f h i li i d h i i hSpasticity and rigidity are 2 types of hypertonic states elicited when examining the tone of limbs. It is important to differentiate between them to arrive at a correct diagnosis.S ti itSpasticity:Seen in pyramidal tract lesionsClassically termed ‘Clasp knife spasticity’ – more tone during the initial part of movement as in opening a pocket knifemovement – as in opening a pocket knifeIt is velocity dependant – should be elicited by fast movement of the muscle groups involvedRigidity:Rigidity:Seen in extrapyramidal lesions – like parkinsonism

Cog wheel rigidity – Tremor superimposed on hypertonia – resulting in intermittent increase in tone during the movement – felt as jerksintermittent increase in tone during the movement felt as jerksLead pipe rigidity – Uniform increase in tone

Velocity independent – does not vary with speed of movement of muscle groups


y p y p g pinvolved

Tone

• How to do it:– Passive rotation of wrist with supination and

pronation at elbow joint with elbow supportedpronation at elbow joint with elbow supported

• Look for:oo o– Hypertonic (upper motor neuron or extrapyramidal lesion)

– Hypotonia

C h l i idit– Cogwheel rigidity (Parkinson)

– Myotonia (increased tone after movement)Myotonia (increased tone after movement)



Power :grade 0–5, e.g. MRC scale; compare right with left testing d d l l ( h ld lb f h kindividual muscle groups (shoulder, elbow, wrist, fingers, hip, knee

and ankle); it is often better to ask the patient to resist you moving their limb than to move it in a certain direction e g whenmoving their limb than to move it in a certain direction, e.g. when assessing triceps and biceps ‘Bend your arms like this and keep them there’


PowerShoulder abduction

Wrist flexion

Elbow flexion

Finger flexion

Elb t iElbow extension

Fi bd tiFinger abduction

Classification of PowerClassification of Power

0 = Complete paralysis

1 Fli k f t ti1 = Flicker of contraction

2 = Movement possible with gravity excluded2 Movement possible with gravity excluded

3 = Movement possible against gravity but not

against resistance

4 = Movement possible against resistance

5 = Normal power5 = Normal power



Reflexes :strike the tendon, not the muscle; test biceps, triceps, supinator, k d kl k l d d lknee and ankle jerks; an extensor plantar indicates a pyramidal tract lesion; if there is no response, consider using a distraction manoeuvre at the time of striking the tendon e g ask the patientmanoeuvre at the time of striking the tendon, e.g. ask the patient to pull apart inversely clasped hands.


Reflexes

Classification of Reflexes

1. Absent

2. Reduced

3. Normal3. Normal

4. Increased4. Increased

5 Greatly increased5. Greatly increased

Remember reinforcement manoeuvres when reflexes are absentRemember reinforcement manoeuvres when reflexes are absent


Sensory examination Sensory examination involves an assessment of pain, light touch, oprioceptionand vibration sense. Assess pain using a Neurotip ® (spinothalamic tract) and light touch using a cotton ball (dorsal columns).Determine whether any abnormality is symmetrical or isolated.



Cerebellar function

The cerebellum has an important role in the coordination of movement:• Perform the finger–nose test looking for ataxia, past pointing and intention tremor (tremor on approach to the finger); heel–shin test should be performed in lower limb examination

d l (d d d h k )• Test rapid alternating movements (dysdiadochokinesis) • Compare right with left • Remember that these tests are unreliable if the limb is weak L k f t h i t l t t b ll di ith th• Look for nystagmus: horizontal nystagmus suggests cerebellar disease with the fast phase towards the affected side

• Assess speech: disjointed and explosive (staccato) speech


Finger – Nose – Test:Finger – Nose – Test:• look for

• intention tremort i ti• past pointing

Dysdiadochokinesis:l k f l d l t• look for slow and clumsy movement

Clinical Pharmacy VI:Clinical Pharmacy VI:yyFirst AidFirst AidAnas Bahnassi PhD CDM CDEAnas Bahnassi PhD CDM CDE

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