Where is the mental state exam used?
Used as part of the physical exam in primary care, etc. (not instead)
It can be used in its entirety or use the parts that are relevant to describe your patient’s mental state of being during the physical examination or more typically your interview
What questions are asked as part of the "thought process" in the MSE?
Organized? Goal Directed?
Circumstantial, Tangential, Loose Associations
What questions are asked as part of the "thought conent" in the MSE?
Obsessions, Delusions,
Suicidal/homicidal Ideation
What is relevant in assessing speech in the MSE?
Rate (slowed – pressured), Rhythm, Prosody
What is relevant in assessing cogniriton in the MSE?
• Orientation, Attention, Concentration • short/long term memory
• Abstraction
• Judgment, Insight
Difference between mood vs. affect?
Mood “ what patient reports’
Affect = what clinician sees
How to make sure older pts can hear you?
Ask patient if they can hear you
Speak slowly and clearly, but don’t
shout
Sit at eye level, face-to-face, hands away from face
Avoid high pitch tones
Reduce background noises
Repeat numbers, letters
tips for communicating with elderly pt with cog. impairment?
Don’t assume patient can not understand
Use simple phrases, short words
Be patient and repetitive
Write down instructions
Don’t exclude patient from the conversation
Families are crucial!
What is in ADLs?
What is in IDLs?
what does the minicog test involve?
how to score mini cog test?
what is not impaired?
recalled all 3 words
OR recalled 1-2 words, and the clock was normal
Social assessments in elderly involves
Formal and Informal Supports Financial Resources
Area Resources
How should you check pulse pressure in elderly?
in 2 places
pulse press ___ with aging
increases
vital sign changes in elderly?
increases -- pulse pressure, premature and atrial ventricular beats
decreases - max heart rate, pulse oximetry, temp
no change - HR, respiratory rate
what is actinic keratosis?
precancerous lesion
what is arcus senilus? what is it a sign of?
a white, gray, or blue opaque ring in the corneal margin
a sign of hypercholesterima
How do you account for cognitive impairment?
First of all, don’t assume the patient can’t understand.
Use simple phrases.
Be patient and repetitive if necessary
Use family members but DO NOT exclude patient from the conversation
Use written instructions if necessary
senile ptosis is caused by the
Fat pads around eyes atrophy and eyelids can become more elastic
in geriatric exam
what are found on cardiovascualr exam?
bruits over carotids
systolic murmurs at right upper sternal border
aortic sclerosis: thickening of wall
aortic stenosis: narrowing of wall
S3 can be heard in CHF, S4 will reveal stiffening of vessels
S3 will be heard in ___. S4 will be heard in ___.
S3 is CHF
S4 is stiffening of the vessels
geriatric
___ rounded back due to overcurvature of spine (disc degeneration)
kyphosis
Older female exam:
breasts atrophy
lithotomy position (where feet are separated in stirrups) can be painful
ovaries no longer palpable
decrease in pubic hair and drier, more delicate vaginal mucosa
uterine/bladder prolapse can be seen
older male exam
decrease in pubic hair and penis size, atrophy of testicles
hyperplasia of prostate, usually benign
common abdomonal exam findings
abdominal bruits
potbellies!
aorta might be widened, so palpate
look for guarding and rebound
common on MSK findings
loss of height and decreased range of motion
less muscle mass
changes in joints due to osteoarthritis
complete wasting of interosseus muscle so that hands are thin and bony
in elderly you have complete wasting of ____ muscle so that hands are thin and bony
interosseus
___ is the
Leading cause of death in adults over the age of 65
falls
why is age (esp over 75) a risk factor for fall
Broad based gate, flexion of cervical spine, hips, knees
Poor gait initiation, stiff turns
Decreased baroreceptor sensitivity
Postural hypotension, vision changes
Decreased total body H2O
Decreased proprioception
risk factors for falls
age
female
low mobility and body weight
impaired gait and blaance
acute illnesses and meds
chronic illnesses that can inc risk of falls
HTN, stroke, MI, arthritis, UTI, depression, diabetes, poor nutrition, chronic pain, pneumonia, arrhythmia
medications that inc the risk of falls include
benzodiazepines, antidepressents, any meds with side effects, ____, _____, and ___.
benzodiazepines, antidepressents, any meds with side effects, caffeine, antihistamines, ACE inhibitors
Intrinsic factors contributing to falls= changes in the person themselves
Slower reflexes, increased postural sway, cognitive impairment, alcohol, meds etc.
falls are associated with
Decline in functional status
“long lie” = need help to get up; predicts decline in functional status
· Nursing home placement
· Increased use of medical services
· Fear of falling
____ predicts decline in functional status after a fall
needing help to get up
Get up and go test
what is normal?
what is impaired?
Less than 10 sec, freely mobile
Less than 20 sec, mostly independent
20-29 sec, variable mobility
Greater than 30 sec, impaired mobility
Single fall = check for
balance/gait problems
Multiple falls = determine multifactorial falls risk (H&P, tests)
Check BP, pulse (supine, standing), vision, cardio, musculoskeletal, neuro
EKG, brain imaging, spine radiographic studies
Hemoglobin, serum urea nitrogen, creatine, glucose
Carotid sinus massage = can uncover carotid sinus hypersensitivity
Mini-Cognitive Exam:
gait/balance evaluation
____ affect is - a large range, “even keel”
euthymia
Normal Development of 18mo
- Motor: walks alone, may ___.
run or climb stairs
Normal Development of 18mo
- Fine motor: drinks from a cup, feeds self with spoon, can help ____.
undress
Nml development of 18 mo
Social/emotional: temper tantrums, ____, affectionate towards familiar face, shows interest in ___ and ___.
Social/emotional: temper tantrums, stranger anxiety, affectionate towards familiar face, shows interest in objects and wants
NML language in 18mo
Language:_____ words, no and can shake head
Language: several single words, no and can shake head
NML cognitive in 18mo
Name simple objects, points to one body part, scribbles, can____ without gesture
follow one step command
Examining an 18mo
- Place child on ____.
- Leave most intrusive parts for last
- Distractions
- Be flexible with order of the exam
Examining an 18mo
- Place child on parents lap, make them feel comfortable
- Leave most intrusive parts for last
- Distractions
- Be flexible with order of the exam
How to tell if a baby is healthy just by walking in the room:
- tone/posture
- ____
- color
- RR
attitude
Determining sick versus well
-Sick:
Color : blue, pale, yellow, rash, red, petechiae
Posture: limp, floppy, tripod position, curled up
Respirations: Shallow, fast, noisy, slow, ______, nasal flare
Attitude: _____.
Determining sick versus well
-Sick:
Color : blue, pale, yellow, rash, red, petechiae
Posture: limp, floppy, tripod position, curled up
Respirations: Shallow, fast, noisy, slow, retractions, nasal flare
Attitude: Irritable, ca't be consoled
-Healthy childre
Color: _____
-Healthy:
Color: pink
Posture: good tone, comfortable
Respirations: Normal
Attitude: consolable
Posture: good tone, comfortable
Respirations: Normal
Attitude: consolable
-Healthy:
Color: pink
Posture: good tone, comfortable
Respirations: Normal
Attitude: consolable
Croup:
3 months to 3 years
low grade fever, _____ always pathological, _____ cough
_____ sign: narrowing of the airway on x-ray
Supportive airway management
Croup:
3 months to 3 years
low grade fever, stridor* always pathological, hoarse cough
steeple sign: narrowing of the airway on x-ray
Supportive airway management
long prodrome of low grade fever, runny nose, cough, vommiting occurs after coughing and coughing is worse with exercise, cough progressively worse, won't eat or drink, not sleeping well, coughing at night, cough improves with steam.
this is ____.
croup
____ is an abnormal, high-pitched, musical breathing sound that is almost always pathological.
Stridor
Stridor is seen in
Trauma, congenital abnormalities, foreign body,___, Inflammatory disease
Trauma, congenital abnormalities, foreign body, metabolic disorders, Inflammatory disease
Epiglotitis
Age: over____ years
stridor, sore throat, drooling, fever
Cough is _____ sounding
thumb print on lateral neck film
inflammation of the epiglottis
Emergency airway management
Epiglotitis
Age: over 3-5 years
stridor, sore throat, drooling, fever
Cough is bark sounding
thumb print on lateral neck film
inflammation of the epiglottis
Emergency airway management
thumb print sign on film indicates ___
epiglottis
Fever breaks in a few days with ___
roseola
tx for roseola
no tx necessary
Once the ____ with Roseola (HHV 6), the child is no longer contagious
rash appears
Pyloric stenosis
Boys more often affected
Usually ____ weeks old
Tx is _____.
Boys more often affected
Usually 2-8 weeks old
Tx is surgery.
_____ stenosis
Projectile vomiting
Electrolyte abnormalities
Hungry!
Pyloric stenosis
Projectile vomiting
Electrolyte abnormalities
Hungry!
Meningococcemia
Flu like symptoms (nonspecific prodrome)
Rash
Slightly ____
____ in color.
Meningococcemia
Flu like symptoms (nonspecific prodrome)
Rash
Slightly raised
Purpelish in color.
Meningococcemia
Gets out of control quickly
EMERGENCY; can be fatal!
Antibiotics first, cultures later
Should give _____.
Watch for signs of sepsis
Penicillin (little resistance)
Meningococcemia (Neisseria meningitidis)
____ classic (soldiers too)
Immunization avaialbile
College student classic
Group A Streptococci scarlet fever
6 year old
Fever
Abdominal pain
Inflammation of the oropharynx with ______ on the soft palate
May be the only pertinent positive
“Sandpaper rash”
“Strawberry tongue”
Group A Streptococci scarlet fever
6 year old
Fever
Abdominal pain
Inflammation of the oropharynx with petechiae on the soft palate
May be the only pertinent positive
“Sandpaper rash”
“Strawberry tongue”
Exam in Group A strep scarlet fever find what
Abdominal pain
Inflammation of the oropharynx with petechiae on the soft palate
May be the only pertinent positive
“Sandpaper rash”
“Strawberry tongue”
Abdominal exam normal
Rash may present on other parts of the body (like palms)
Group A Streptococci scarlet fever
6 year old
Fever
_______ pain
Inflammation of the oropharynx with petechiae on the soft palate
Rash may present on other parts of the body (like palms)
Antibiotics
Treat ____, but not an emergency
Strep A Scarlet fever
6 year old
Fever
abominal pain
Inflammation of the oropharynx with petechiae on the soft palate
Rash may present on other parts of the body (like palms)
Antibiotics
Treat early, but not an emergency
Cigarette burns: Abuse
“Rash” on top of ____.
Parents don’t know how it got there
LACK of info makes diagnosis
Symmetric, suddenly ____.
Finding doesn’t fit with story
Cigarette burns: Abuse
“Rash” on top of foot.
Parents don’t know how it got there
LACK of info makes diagnosis
Symmetric, suddenly appears.
Finding doesn’t fit with story
Intussusception
Intermittent, colicky abdominal pain
Currant ____ stool
Vomiting
Elevated _____ level is a clue
Indicates _____ necrosis
Intermittent, colicky abdominal pain
Currant jelly stool
Vomiting
Elevated lactate level is a clue
Indicates intestinal necrosis
Intussusception
Emergency
3 months-1 year of age
Radiographic “____ sign”
Emergency
3 months-1 year of age
Radiographic “donut sign”
