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Tying Together the Clinical Examination
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November/December 2006 710 The Journal for Nurse Practitioners - JNP JNP Over the course of the past year or so I have tried to coach you in understanding the nervous system and how it applies in the clinical setting. I will now try to put the entire examination together for you in a clinical setting. The components of the examination include mental status testing, cranial nerve testing, motor examination, sensory examination, gait and coordi- nation, and reflex testing. For the most part, men- tal status testing can be completed in a general interview with the patient. If conversation appears normal—with good fluency, organized thought process, good attention to detail—I would not pro- ceed with any other form of testing. Often during the interview the patient will make references to time, places, and dates that indirectly assess orien- tation and the like. Therefore, formalized testing is not necessary. I do formalized screening tests such as the Mini Mental Status Examination or the clock drawing test if the patient has a direct complaint about memory or thought process, or, if during my initial interview, I become suspicious of cognitive prob- lems. You also may screen for depression, because this can mimic some of these symptoms. Cranial nerve (CN) testing is next. Please refer to my article that details this in the November/ December 2005 issue of JNP. Quickly, I routinely do not test CN I, the olfactory nerve. I bundle CN II, III, IV, and VI together because these are the CNs that have to do with the eyes. CN V and VII are tested together because they control the facial sensory and motor functions. CN VIII is tested alone; CN IX and X are tested together (this is the cough and gag). CN XI and XII finish the examination. Motor function is tested by examining the indi- vidual muscle groups using yourself (the examiner) as the control (assuming normal strength). The major muscle groups include deltoids, biceps, tri- ceps, hip flexors, leg flexors, and extensors along with dorsi and plantar flexion. Each group should be of normal and equal strength, with normal tone and bulk. The sensory examination is by far one of the most difficult examinations to perform and inter- pret because it is 100% subjective, so be careful how you interpret your findings. This is done with a pin to test sharp and dull sensation and a 128 Hz tuning fork to test vibration. Each is tested on the lower extremities bilaterally, starting at the great toe. If sensation is altered, the test is moved up the limb to determine at what sensory level it becomes “normal.” This is called determining a sensory level; it helps to establish the level of decrement of injury with peripheral neuropathy or within the spine. Gait and station often can be assessed early when the patient is walking into the office or exami- nation room when he does not even realize he is being observed. If his gait is not fluid with normal steppage and associated movements or appears unstable, I will do more formalized testing or if I pick up a weakness on examination or other focal find- ing. Here, I will also incorporate my coordination testing, checking Romberg, tandem walking, and Tying Together the Clinical Examination DIAGNOSTIC TIPS Barbara Bishop Editor’s note: With this issue, Barbara Bishop leaves JNP as a columnist. We thank her and wish her well in her new endeavors.
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Transcript of Tying Together the Clinical Examination
November/December 2006710 The Journal for Nurse Practitioners - JNP
JNP
Over the course of the past year or so I have triedto coach you in understanding the nervous systemand how it applies in the clinical setting. I will nowtry to put the entire examination together for youin a clinical setting.
The components of the examination includemental status testing, cranial nerve testing, motorexamination, sensory examination, gait and coordi-nation, and reflex testing. For the most part, men-tal status testing can be completed in a generalinterview with the patient. If conversation appearsnormal—with good fluency, organized thoughtprocess, good attention to detail—I would not pro-ceed with any other form of testing. Often duringthe interview the patient will make references totime, places, and dates that indirectly assess orien-tation and the like. Therefore, formalized testing isnot necessary.
I do formalized screening tests such as the MiniMental Status Examination or the clock drawingtest if the patient has a direct complaint aboutmemory or thought process, or, if during my initialinterview, I become suspicious of cognitive prob-lems. You also may screen for depression,because this can mimic some of these symptoms.
Cranial nerve (CN) testing is next. Please referto my article that details this in the November/December 2005 issue of JNP. Quickly, I routinelydo not test CN I, the olfactory nerve. I bundle CNII, III, IV, and VI together because these are theCNs that have to do with the eyes. CN V and VIIare tested together because they control thefacial sensory and motor functions. CN VIII is
tested alone; CN IX and X are tested together(this is the cough and gag). CN XI and XII finishthe examination.
Motor function is tested by examining the indi-vidual muscle groups using yourself (the examiner)as the control (assuming normal strength). Themajor muscle groups include deltoids, biceps, tri-ceps, hip flexors, leg flexors, and extensors alongwith dorsi and plantar flexion. Each group shouldbe of normal and equal strength, with normal toneand bulk.
The sensory examination is by far one of themost difficult examinations to perform and inter-pret because it is 100% subjective, so be carefulhow you interpret your findings. This is done witha pin to test sharp and dull sensation and a 128 Hztuning fork to test vibration. Each is tested on thelower extremities bilaterally, starting at the greattoe. If sensation is altered, the test is moved upthe limb to determine at what sensory level itbecomes “normal.” This is called determining asensory level; it helps to establish the level ofdecrement of injury with peripheral neuropathy orwithin the spine.
Gait and station often can be assessed earlywhen the patient is walking into the office or exami-nation room when he does not even realize he isbeing observed. If his gait is not fluid with normalsteppage and associated movements or appearsunstable, I will do more formalized testing or if I pickup a weakness on examination or other focal find-ing. Here, I will also incorporate my coordinationtesting, checking Romberg, tandem walking, and
Tying Together the ClinicalExamination
DIAGNOSTIC TIPS
Barbara Bishop
Editor’s note: With this issue,
Barbara Bishop leaves JNP as a
columnist. We thank her and wish
her well in her new endeavors.
710-711_YJNP300_Bishop_CP 11/15/06 1:41 PM Page 710
www.npjournal.org The Journal for Nurse Practitioners - JNP 711
finger-to-nose testing. (Please refer to the July/August 2006 edition of JNP for a more detailedassessment of gait and station.)
Finally I check reflexes. This also can be trickybecause patients can override or overexaggeratethem, so this is when the patient will need distrac-tion techniques to help determine the true level ofreflex. Also, the lack of a good reflex hammer (andthose orange triangle reflex hammers are not goodreflex hammers!) can throw off your results. Andknow your reflex hammer—knowing how muchpressure to apply to get consistent results isimportant. The only way to do this is with practice.
Believe it or not, when you get proficient at this,the entire screening examination should take youonly about 5 minutes.
1555-4155/06/$ see front matter© 2006 American College of Nurse Practitioners Incdoi:10.1016/j.nurpra.2006.10.012
Miscellaneous Code Changes
Continued from Page 709are working with health care providers to becomemore effective and culturally aware of how theyprovide care to diverse populations. As part of anational initiative, they are recruiting healthproviders to participate in a free online program,“A Family Physician’s Practical Guide to CulturallyCompetent Care,” to ensure that Medicareproviders are prepared to effectively serve diversepatients. The program is a case study-based cur-riculum, featuring video vignettes and a diversegroup of providers and clinical staff members ata fictional practice setting which reinforceslearning points throughout the modules.Available to all health care providers and accred-ited with continuing education units, the pro-gram is available at www.thinkculturalhealth.org.The National Standards for Culturally andLinguistically Appropriate Services in HealthCare are available at www.omhrc.gov/templates/browse.aspx?lvl=2&lvllD=15
CMS Mailing ListsCMS offers a way for you to receive consistentand accurate information about news, policychanges, and updates by subscribing to their freemailing lists, also known as listservs. To view allavailable listservs, visit www.cms.hhs.gov/apps/mailinglists/ and subscribe using your emailaddress. If at any time after subscribing you findthat certain listservs are not helpful, return to thatsame page to unsubscribe.
1555-4155/06/$ see front matter© 2006 American College of Nurse Practitionersdoi:10.1016/j.nurpra.2006.10.011
Barbara Bishop, MS, ANP-C, CNRN, MSCN, works atVirginia Beach Neurology in Virginia Beach, Va. She canbe reached at [email protected].
Jan DiSantostefano, NP, is a family and women’s healthnurse practitioner at the SAS Institute, Inc., in Cary, NC.She can be reached at [email protected].
710-711_YJNP300_Bishop_CP 11/15/06 1:41 PM Page 711
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