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
PharmacistsPharmacists
Anas 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 to
1. 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
y
well?
3. Listen during the first part of the
ti d l t ti t t lk
extract 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 p
5. 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 to
6. Duration and speed of onset of the
patient’s symptoms are particularly You need to
structure the
i i i
p y p p y
important.
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
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 to
7. 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:
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
history
and 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 problems
worthy 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 the
Disease Informal Label
A th COPD B hiti hInquire about the
following common
ill
Asthma, COPD Bronchitis, emphysema
Ischemic Heart Disease Angina
Myocardial Infraction Heart Attack
illnesses: Myocardial Infraction Heart Attack
Cardiac failure Fluid on the lung
Diabetes Mellitus Blood sugar
Remember that
patients often
g
TB
Surgery
patients often
employ informal
Stroke, epilepsy Fits
Hypertension Blood pressure
labels: Hypercholesterolemia
Venous thromboembolism Clots
Rheumatic fever
Major 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 ; p
ordinary 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 History
A 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 Score
Wh 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 10
A score <7 suggests cognitive dysfunction.

Mini Mental State Examination
Test Question Max ScoreTest Question Max Score
Time 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 5
Concentration
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 3
hand, (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:
Inspectionp
Note any abnormality of resting limb position (contracture or palsy),
involuntary movements (seizure activity, tremor and chorea), muscle wasting,
fasciculation and gait.
Cranial nerves
Examine cranial nerves II–XII; Cranial nerve I (olfactory nerve) is not
routinely assessed.

Tests Routinely Performed on Cranial Nerves
Cranial 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 against
resistance 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 examination
For motor examination, assess tone, power and reflexes, starting proximally and
moving distally; compare right with left. Give the patient clear instructions when
examining power. It is important to distinguish between upper and lower motor
neurone 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 first
few 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 lesions
Classically termed ‘Clasp knife spasticity’ – more tone during the initial part of
movement as in opening a pocket knifemovement – as in opening a pocket knife
It is velocity dependant – should be elicited by fast movement of the muscle groups
involved
Rigidity: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 jerks
Lead pipe rigidity – Uniform increase in tone
Velocity independent – does not vary with speed of movement of muscle groups
y p y p g p
involved

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)

Motor examination
neurone weakness.
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’

Power
Shoulder 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

Motor examination
neurone weakness.
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.

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, oprioception
and 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 tremor
t i ti• past pointing
Dysdiadochokinesis:
l k f l d l t• look for slow and clumsy movement

Clinical Pharmacy VI:Clinical Pharmacy VI:yy
First AidFirst Aid
Anas Bahnassi PhD CDM CDEAnas Bahnassi PhD CDM CDE
abahnassi@gmail.com
http://www.twitter.com/abpharmp p
http://www facebook com/pharmaprofhttp://www.facebook.com/pharmaprof
http://www linkedin com/in/abahnassihttp://www.linkedin.com/in/abahnassi

Lecture Three: Initial Patient Assessment

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Lecture Three: Initial Patient Assessment