ANCC PMHNP EXAM PREP CHPT 6 Advanced Health and Physical Assessment (Physical, Neurological, Laboratory, Immunizations)

PHYSICAL EXAM Reasons to be familiar with the physical exam in psychiatry: Ans- To be able to detect underlying medical problems To be familiar with a screening neurological exam and to be able to rule out neurological problems that may manifest as symptoms of a psychiatric problem To be able to differentiate normal and abnormal signs and symptoms To know when to refer NEUROLOGICAL EXAM Reflexes (biceps, triceps, brachioradialis, patellar, Achilles, plantar) Ans- Grade reflexes and note symmetry between right and left sides. Check primitive reflexes in infants (head lag, flexion, rooting, grasping, Moro, glabellar, Babinski). A positive Babinski (fanning of toes and dorsiflexion of the great toe) is normal ininfants up to age 2 years. NEUROLOGICAL EXAM Cranial nerves (mnemonic italicized in parentheses) (On Old Olympus Towering Top, A Finn And German Viewed Some Hops) Ans- Olfactory: 1st (On) * Test sense of smell and ensure patency of the nasal passages. * Have the client close eyes and test each nostril separately while other is occluded, asking the client to identify familiar odors. Optic: 2nd (Old) * Test vision using Snellen chart or other suitable chart depending on the client's acuity and ability to cooperate. * Examine the inner aspect of the eyes with the ophthalmoscope. * Test peripheral vision using the confrontation test. Oculomotor: 3rd (Olympus') * This is the motor nerve to the five extrinsic eye muscles. Test together with cranial nerve 4 (trochlear) and cranial nerve 6 (abducens; see below). * Test the extraocular movements (EOMs). * Check the equality of pupils, their reaction to light, and their ability to accommodate. * Test the corneal light reflex (when shining a light at the bridge of the nose, the light should appear symmetrically in both eyes). Trochlear: 4th (Towering) * Use the same process as cranial nerve 3 (oculomotor) and cranial nerve 6 (abducens). Trigeminal: 5th (Motor division; Top) * Palpate the masseter muscles with the fingertips while the client clenches his or her teeth. * Look for disparity in tension between the two muscles, which can indicate paralysis on the weak side. * Look for tremor of the lips, involuntary chewing movements, and spasm of the masticatory muscles. Trigeminal: 5th (Sensory division) * Test tactile perception of the facial skin by touching with a wisp of cotton. * Test corneal reflex with wisp of cotton. * Test superficial pain of the skin and mucosa with pinpricks. * Test the sense of touch in the oral mucosa. Abducens: 6th (A) * Use the same process as for cranial nerves 3 (oculomotor) and 4 (trochlear). Facial: 7th (Motor division; Finn) * Inspect the face in repose for evidence of flaccid paralysis. * Test by asking the client to elevate eyebrows, wrinkle forehead, close eyes, frown, smile, and puff cheeks. Facial: 7th (Sensory division) * Test taste for sugar, vinegar, and salt. Acoustic: 8th (And) * Check hearing with the audiometer or by the whisper test. * Check for hearing loss using the Weber and the Rinne tests. Glossopharyngeal: 9th (German) * Test together with cranial nerve 10 (vagus; see below). Vagus: 10th (Viewed) * Test for elevation of the uvula by having the client open his or her mouth and say "ah." * Test the gag reflex by touching the back of throat with a tongue blade. Accessory spinal: 11th (Some) * Test the strength of the sternocleidomastoid and trapezius muscles against resistance of your hands. Hypoglossal: 12th (Hops) * Look for tremors and other involuntary movement when the client protrudes his or her tongue. NEUROLOGICAL EXAM Coordination and fine-motor skills Ans- * Equilibrium: Check by administering the Romberg test: have the client stand up straight with feet together, arms by sides, and eyes closed. Only slight swaying would be normal, and the client will be able to sustain this pose for approximately 5 seconds. More than slight swaying suggests cerebellar ataxia or vestibular dysfunction. * Diadochokinesia: Ability to perform rapid alternating movements (such as patting knees alternating palm and back of hands, touching thumb to each finger); the client should be able to smoothly execute these movements and maintain the rhythm. *Dyssynergia: Finger-to-nose test, heel-to-knee test * Handwriting * Gait: Observe client walking. NEUROLOGICAL EXAM Sensory functions Ans- * Pain: Check sensation to pain with pinprick, and compare on each side of body. * Temperature: Check temperature if sensation to pain is abnormal. * Superficial touch: Test with wisp of cotton. * Two-point discrimination: Apply pins to skin simultaneously; ask the client if he or she feels one or two pinpricks. * Stereognosis: Tests the ability to distinguish forms by placing objects in the client's hands while his or her eyes are closed. * Graphesthesia: Tests the ability to identify figures, letters, or words by tracing the figure on the skin of the palm of the hand. NEUROLOGICAL EXAM Motor functions Ans- * Muscle mass: Measure muscle mass to check for atrophy or hypertrophy. * Muscle tone: Tension is present when the muscle is resting. * Muscle strength: Check muscular strength against resistance. Be aware of abnormal muscle movements. NEUROLOGICAL EXAM Neurological soft signs Ans- * Dysdiadochokinesia: Inability to perform rapid alternating movements; result of a lesion to the posterior lobe of the cerebellum * Astereognosis: Inability to discriminate between objects based on touch alone; result of a lesion in the parietal lobe * Choreiform movements * Tics * Agraphesthesia: Inability to recognize letters or numbers "drawn" on the client's hand with a pointed object * Facial grimacing * Impaired fine-motor skills * Abnormal blinking * Abnormal motor tone Physical Exam Vital Signs Ans- Measure height, weight, blood pressure (on children ages two or older), pulse, respirations, temperature, and head circumference (during the first 2 years). Use growth charts for infants and children. * Greater than 85th percentile for body mass index (BMI) places a child at increased risk for being overweight. Use BMI charts ** Normal: 20 to 25 ** Overweight: 26 to 29 * Obese: 30 to 35 High BMI is a risk factor for diabetes, heart disease, stroke, hypertension, osteoarthritis, and some forms of cancer. Be alert for high BMI if the client also is being prescribed psychotropic meds with a propensity for weight gain, especially atypical antipsychotics. * If a client is presenting with elevated temperature and also is taking psychotropic meds such as carbamazepine (Tegretol) or clozapine (Clozaril), be alert for agranulocytosis. Physical Exam Head, skin, nails Ans- Note the color and integrity of the skin and whether lesions are present. Note if the skin is well-hydrated, dry, or scaly. Assess skin turgor. Palpate the skin's temperature. Note any unusual moles or other lesions. Look at hair texture and distribution. Determine the quality of the nails, noting splitting, clubbing, or onychomycosis. Check capillary refill. Examine head, scalp, sutures, and fontanelles (if infant). Check cranial nerve 7 (facial nerve) for symmetry (have client smile, frown, wrinkle forehead, puff cheeks). Be alert for Stevens-Johnson syndrome (life-threatening rash), especially if the client is taking carbamazepine or lamotrigine (Lamictal). Cancerous moles can be detected by using the acronym ABCDE—asymmetry, border irregularity, color variation, diameter greater than 6 millimeters, and elevation. Physical Exam Eyes Ans- Check visual acuity using the Snellen chart (tests cranial nerve 2: optic nerve). Test peripheral vision using the confrontation test (tests cranial nerve 2: optic nerve). Note the symmetry of eyes and the appearance of orbits, eyelids, and brows. Inspect the sclera. Assess corneal sensation with wisp of cotton (tests cranial nerves 5 and 7). Assess papillary reaction to light and accommodation (tests cranial nerves 3, 4, and 6). Assess the six cardinal fields of gaze (extraocular movements; tests cranial nerves 3, 4, and 6). Assess corneal light reflex. Light reflections should appear symmetrically in both pupils (tests cranial nerves 3, 4, and 6). Examine the inner aspect of the eyes with the ophthalmoscope (tests cranial nerve 2). Be aware that many psychotropics can cause blurry vision (an anticholinergic side effect). Quetiapine (Seroquel) may cause cataracts. Physical Exam Ears Ans- Check for configuration, position, and alignment of auricles. Test auditory acuity (cranial nerve 8) with the whisper test or audiometer. Inspect external auditory canals with otoscope for redness, swelling, or excess cerumen. Tympanic membrane should be translucent pearly gray without retractions or bulges. Physical Exam Nose and Sinuses Ans- Note the appearance of the external nose and whether it is smooth, intact, symmetric, midline, has discharge, or is flaring. Assess nasal patency. Assess sense of smell. Inspect internal nasal cavity for patency and septal deviatio