Evaluating the patient

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Evaluating the patient
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Scientific Method

• Identify the problem
• Propose a solution formulate a hypothesis
• Develop procedures to test eh hypothesis
• Collect data relevant to the hypothesis
• Analyze the data
• Modify the hypothesis, formulate a new one or
  reach a conclusion based upon the analysis

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Scientific method as a clinical method

• Gather information about the patients impairment
  referral, hx., examination
• Evaluate the subjective reports (symptoms) and
  objective test results (signs) for which are
  actually relevant
• Decide if a collection of symptoms and signs
  exists syndrome

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• Seek relationships among symptoms and signs so as
  to know the involvement of the body or the mental
  status
• If the symptoms are a syndrome that has a known
  course and outcome, state a prognosis for
  eventual recovery
• From the hs, examination and facts, formulate a
  decision on how the patients condition will
  affect daily life

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Things to remember about clinical methods

• Data collection and analysis is basically using
  the scientific method to solve a specific
  problem finding a clinical solution
• Learn from experiences the process repeats
  itself!
• The process is ongoing constant changes occur,
  therefore routinely re-evaluate
• Missing data leads to flaws in diagnosis

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Referrals

• Personal information
• Pts. location at the time of the referral
• Short description of current status
• Referral source

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Reviewing medical records

• Patient ID
• Personal history occupation, marital status,
  children, residence, hobbies, employment and
  educational history
• Medical Hx. previous illnesses, injuries,
  medical conditions, current disabilities,
  complaints.

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• Communication issues previous CVAs,
  disorientation, confusion, distorted sph, loss of
  consciousness, seizures, chronic medical
  conditions
• e. g., diabetes, vascular disease, heart disease,
  pulmonary disease, hearing loss, visual problems

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Neurologic Examination

• Cranial nerves
• Motor system
• Muscle tone and range of movement
• Hypertonia increased resistance to passive
  movement---2 forms
• Spacticity (increased stretch reflex causes
  muscles to be hard and tense)---motor cortex or
  corticspinal tract---UMN
• Rigidity (relaxed limb evenly resists movement in
  any direction
• Extrapyramidal system lesions---LMN

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• Decreased resistance to passive movement
• Hypotonia (flaccidity)rag doll phenomena

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Muscle Strength

• Active movement against resistance or gravity
• Active movement against gravity but not
  resistance
• Active movement only when gravity is eliminated
• Flicker or trace of contraction
• 0 No contraction

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Reflexes

• Deep (tendon)
• patellar
• Superficial
• Pathological (primititive)
• Gag
• Swallow
• Corneal

0 Absent 1 Diminished 2 Normal 3 Brisk
(faster, greater amplitude) 4 Clonus
(rhythmic contraction and relaxation
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Motor exam common terms

• Athetosis slow, writing movements involuntary
  purposelessbasal ganglia/ex-pyr. Sys.
• Dystonia abnormal, involuntary contractions or
  postures

• Myoclonus short bursts cause abrupt, brief
  movements cerebellar
• Fasciculations (muscle) Fibrillations (muscle
  fiber)
• Both are LMN indicators

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Common terms

• Gait walk
• Festinating gait running, tiny shuffling
  walkParkinsons
• Steppage gait
• Waddling
• Dancing gait

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Sensory system examination

• Evaluation to somesthetic (bodily) senses pain,
  numbness or abnormal sensations
• Hyperesthesia abnormal sensitivity to
  stimulation
• Paresthesia disturbance in peripheral nerves
• Anesthesia complete loss of sensation

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Sensory system exam

• Pain, pressure, touch
• Deep sensation muscles, tendons and joints
• Body position and vibration
• Superficial sensation skin
• Light touch, pinprick, and temperature

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Sensory Equilibrium

• Dizziness Vertigo
• VIII nerve lesions (acoustic neuroma)
• Vascular problems of brainstem or cerebellum
• Menieres disease (increased pressure in the
  inner ear Vestibular system)
• Evaluated by stance, gait, and nystagmus

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Consciousness and Mentation

• Confusion lowered overall level of
  consciousness
• Lethargy drowsy, may fall asleep at
  inappropriate times
• Amnesia complete loss of memory for a time.
  Note Post Traumatic Amnesia (PTA)

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Seizures

• Note frequency, duration, precipitating events,
  and changes in sensation or mentation (aura),
  NOTE physical status AFTER the seizure
• General causes alcohol or drug withdrawal, CNS
  infections, hypoglycemia, and other diseases

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Types of seizures

• Gran Mal convulsion
• Massive discharge of neurons in brain causes
  contraction of all muscles in the body
• Last about 1-3 minutes
• Petit mal brief loss of consciousness lt 1 min.
• Bilateral brain dysfunction

• Partial Seizures
• Focal seizures
• localize discharge on neurons
• Partial loss of consciousness
• Fleeting duration
• Clonic movements of individual muscle groups
• Localized brain dysfunction

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MMSE Scoring (Folstein, Folstein McHugh,
1975) 25-30 Normal Adult X lt 25 indication of
compromised mental status (MMSE was on Judging
Amy last week!)
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Personal history Mr. Shaw is a 55-y/o
accountant (college grad). Married, with two
children son 28, daughter neither living at
home. Wife (Florence) is a secondary-school
teacher. Nonsmoker x 10 yrs. Occasional social
ETOH nonabuser. Both parents deceased (mid-80s),
apparently of natural causes. Employed at time of
apparent neurologic incident. Medical history
Past medical history includes adult-onset
diabetes mellitus diagnosed in 1991, hypertension
diagnosed 1993, and a possible TIA in March of
last year. The patient's wife reports that at the
time of the apparent TIA they were watching
television when the patient became confused, did
not answer questions, and seemed not to
understand. The patient's symptoms apparently
cleared in an hour or two, and they did not seek
medical advice or assistance. Medications on
admission include tolbutamide 500 mg twice a day,
chlorothiazide 500 mg twice a day, which
apparently control the patient's hypertension and
diabetes, and occasionally aspirin. Background
The patient was accompanied to this medical
center by his wife, who provided this
information. The patient apparently was in good
health until this apparent neurologic event,
which occurred at approximately 0815 hrs this
day. The patient was getting dressed for work
when he experienced a sudden onset of speech
difficulties and leg weakness. The patient did
not vomit, lose consciousness, or report double
vision, nausea or vertigo. He arrived at the
emergency room ( medical center at 0905 hrs. The
neurologic examination began at approximately
0920 hrs. Habits The patient is an ex smoker
(0.5 ppd x 10 years) and has not smoked for
approximately the past 10 years. The patient
apparently drinks three or four glasses of wine
per week and other alcoholic drinks occasionally,
but his wife reports that he has never been a
heavy drinker. Physical examination The patient
looks his stated age and is in no apparent
distress. He appears alert and is oriented x 3.
Vital signs Blood pressure 162/89, pulse 72,
temperature 98.6, respiration 18. HEENT exam No
signs trauma or deformation. Moist mucous
membranes. Neck negative for lymphadenopathy or
thyromegaly. No carotid bruit. Cardiovascular
exam Normal S 1, 52, without gallop or murmurs.
Lungs Clear to auscultation. Abdomen soft land
nontender. No organomegaly or palpable masses.
Lower extremities No pedal edema. Neurologic
examination The patient is globally aphasic.
Listening comprehension evaluation showed that he
is able to follow very simple commands like
"close your eyes" or "open your mouth." He is
unable to give yes-no answers to questions. He is
a little bit confused as to right/left commands.
He is unable to do complex commands. Reading
evaluation showed the patient unable to to
identify a letter. He had paraphasic errors in
single-word identification (e.g., "wrisp" for
"wrist"). The patient was unable to follow
commands on reading because of inability to
comprehend. Expression evaluation showed that the
patient unable to read a narrative. He was unable
to repeat "no ifs, ands, or buts." He was also
unable to name objects like watch or pin. Cranial
nerve examination It was difficult to examine
the patient's visual acuity because of his
aphasia. Acuity appears within normal limits, but
the patient exhibits a questionable right-sided
field cut. Funduscopic examination showed no
evidence of papilledema. His pupils are 3mm to 4
mm bilaterally, round, equal, and reactive to
light and accommodation. He had intact
extraocular movements. His corneal relexes are
present bilaterally. His jaw jerk was 1 .He had
symmetrical nasolabial folds and wrinkles. His
tongue is midline and so is his uvula. He has
symmetrical gag reflex bilaterally. He has
symmetrical strength in his shoulders
bilaterally. Motor examination The patient has
no pronator drift and no involuntary movements.
His muscle tone is normal bilaterally. His
strength appears 5/5 on the left and 4/5 in the
right upper extremity and 3/5 in the right lower
extremity. Grasp reflex on right. He had external
rotation in his right lower extremity. His
coordination exam was unremarkable for dysmetria.
Deep tendon reflexes are 2 on the left and 3 on
the right, 1 in both ankles. Plantar reflex on
right. Sensory examination Impossible to
establish accurately because of patients
aphasia. However, the patient withdraws both
lower and upper extremities to pinprick stimuli.
Gait The patient walks slowly, but with
symmetrical arm swings bilaterally. Mild dragging
of right foot. Problem list 1 .Probable LH
stroke 2. Aphasia 3. Hypertension 4. A-onset
diabetes mellitus
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Behavioral and Cognitive Changes of Brain Damage

• Presence of these changes are dependent upon
• Previous Personality and Intellect
• Location and extent of injury
• Psychosocial support system
• Such complications can compound the evaluation
  process

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Responsiveness

• Hyperresponsive
• nonresponsive
• Increased impulsivity
• Lacking of impulse
• Cognitive style
• Reflective proceed slowly, fewer errors
• Impulsive style respond quickly more errors

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Perseveration

• Repetition of responses that are no longer
  appropriate
• Frequency and persistence of the behavious
  depends on the severity of the BD
• May be seen in
• Unilateral injury to either hemiphere
• Generalized damage due to TBI
• Middle stages of dementia
• Usually occurs in the first few days/weeks
  following the injury

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Cognitive Changes

• Concreteness and abstraction difficulties
• Concrete loss of abstract attitude
• Unable to understand literal meanings
• Difficulty with metaphors and idioms
• Difficulty with humor, sarcasm, proverbs
• May contribute to BD pts. Egocentrism---cant
  accept another point of view

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• Concreteness leads to difficulties with
  problem-solving---only see the simplest solution!

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Impaired Self-Monitoring

• Pts have difficulty recognizing their own
  performance in structured or unstructured
  circumstances
• May fail to recognize errors in treatment,
  inappropriate behavior in social situations
• Usually in pts with diffuse BD than those with
  focal lesions
• More often infrontal or temporal lobe lesions

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Impaired Error Anticipation

• Some pts. Recognize their errors but cant
  anticipate or prevent them
• Posterior lesions usually find it funny
• Anterior lesions usually dismayed by the error

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Impaired Focus and Concentration

• Slow to focus implies pt performance improves
  with time
• Difficulty holding concentration implies
  performance will deteriorate over time
• Note pattern for when an activity changes

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Impaired Sequencing

• Difficulty perceiving, retaining, reporting and
  reproducing sequential information
• Temporal sequencing?????
• Pointing, in order to a series of objects or
  pictures
• Often found in frontal lobe damage in the
  language dominant hemisphere

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Disturbances of Personality and Emotion

• Emotional Lability BD maylead to exaggerated
  swings in emotional expression
• The emotion is correct but the magnitude of the
  reaction is disproportionate to the stimulus
• May be expressed as uncontrolled crying
• Pseudobulbar affect failure to suppress a
  primitive reflex
• May be expressed as excessive laughter---especiall
  y if pt feels stressed or threatened

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Irritability and Low Frustration Tolerances

• Pt may be prone to emotional outburst, probably
  due to low frustration tolerance
• Different from emotional lability

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Intolerance vs. Lability

• Frustration has visible early signs
• Progressive state of agitation
• Reaction can be diverted if one recognized the
  signs

• Lability happens rapidly
• Dissipates rapidly
• A reaction to one event

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SLP Interviewing the patient

• Find a quiet spot with few distractions
• Include a family member, if possible
• Tell the patient who you are!!!
• Make the patient physically comfortable
• Get the patients side of the story
• Be patient listen carefully
• Talk at the level of the patient avoid jargon

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More on interviewing

• Do your homework ahead of time!
• Treat the patient as an adult treat with respect
• Prepare the patient for what is going to happen

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Ok, its time for testing..

• Explain the purpose of the testing
• Describe the type of tests to be administered
• Explain how the information will be analyzed and
  how it will be protected
• Explain the test procedures
• ASK the patient how he/she feels about taking ANY
  test

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Testing Brain Injured Patients

• Increased levels of
• Patience
• Empathy
• Understanding
• Expertise (experience) with test administration
  and interpretation
• Observation rules for clinicians

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General guidelines for testing

• Do your homework
• Choose an appropriate location for testing
• Schedule testing at a time to maximize the
  patients performance
• Make the testing process collaborative
• Select appropriate tests

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Test Selection

• A sample of a large of performances at
  different levels of difficulty
• Test should locate a performance that is
  error-free, an area of complete breakdown and
  several intervening levels
• Standardized test so that results are reliable
  from test to test

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Test Selection, cont.

• Test should consistently input modalities,
  cognitive processes used, and output modalities
  needed to complete the test instructions
• Test responses should be recorded in terms of
  quality and correctness
• Test items should be sufficient to permit
  reliable estimates of performance

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Test Selection, cont.

• Test should suggest reasons for patient
  performance
• Test should permit predictions about recovery

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Guidelines, cont.

• Use patients performance as a guide for what and
  how you test.
• Use standardized tests and test procedures if you
  want to generalize the patients behavior to
  others or to other test administrations
• Evaluate the normative sample of the test
• Evaluate the normative statistics of the test

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Considerations for Standardized Testing

• Reliability can it be repeated with the same
  result?
• Inter-rater reliability
• Intra-rater reliability

• Validity
• Content validity how well does the content of a
  test related to known theory, models or concepts
• Construct validity are the content and test
  procedures relevant to theory, etc.

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Guidelines, cont.

• Get a large enough sample of patients overall
  communicative behavior to allow for test-retest
  comparisons
• Read the manual consider the norm group and
  sample size
• Generally bigger sample size is betterwhy?

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Reasons for SLP testing

• To diagnose a communication disorder
• To determine a prognosis for the CD
• To make decisions on management and focus of the
  CD
• To measure either the recovery process or the
  efficacy of the treatment process

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Differential Diagnosis

• To differentiate among other communicative
  disorders
• To label or not to label.

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Establishing a prognosis

• Prognosis is a prediction about the course of
  the recovery and about the extent of the
  recovery-----must consider
• Neurologic findings stroke recovery patterns
• Associated conditions general vs. Impaired
  health, sensory and motor involvement
• Patient variables age, gender, education,
  occupation, premorbid intellingence, handedness,
  personality and emotional state

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Prognosis, cont.

• Nature and severity of the communication
  impairment(s)
• For example, Broca type aphasics are better
  predictors of recovery than Wernickes---why?
• Consider the predictive validity of some
  standardized tests.
• Minnesota Test for Differential Diagnosis of
  Aphasia (MDTTA) uses a patient profile approach

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Predictive validity, cont.

• Porch Index of Communicative Ability (PICA) uses
  a statistical prediction method
• Uses statistical analyses to determine the
  relative contributions of some variables
• HOAP slope High-overall prediction)---uses the
  9 highest scores of the 18 subtests as a
  predictor of recovery
• Prognostic treatment as a precursor to stating a
  prognosis

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Treatment Efficacy

• Single subject design is an excellent means of
  establishing baseline performance levels -for
  measuring patients response to treatment
• For cues to the clinician to change tx.
  Procedures
• For evaluating generalization of behaviors
• For contributing to our knowledge base on
  neurogenic communication disorders

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Efficacy and Functional Outcome

• Efficacy whether treatment has a positive
  effect
• As measured on a standardized test
• Outcome whether tx. provided meaningful benefit
• Functional outcome tx improves patients daily
  life competences or personal well-being

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Therefore,

• In SLP, functional communication is an approach
  to assessment and treatment that focuses on the
  patients daily life communicative success or
  lack thereof. (Brookshire)
• Communication is not dependent on precise
  messages (linguistic) but upon the exchange of
  ideas despite errors in phonlogy, syntax, word
  choice, etc.-----function of language, not form

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• Promoting Aphasics Communicative Effectiveness
  (PACE)
• Davis and Wilcox, 1985)
• Focuses on daily-life communications and on
  socially relevant aspects of communication
• In health care, functional communication means
  able to communicate basic needs and wants---what
  does that mean to you?

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Situations rated by the Communicative
Effectiveness Index (CETI)   Item Situation  
1.                              Getting someones
attention 2.                              Getting
involved in group conversations about
him/her 3.                              Giving
yes and no answers appropriately 4.          
                    Communicating his/her
emotions 5.                             
Indicating he/she understands what is being said
to him/her 6.                              Having
coffee, time visits and conversations with
friends and neighbors 7.                          
    Having a one-to-one conversation 8.           
                   Saying the name of someone
whose face is in front of him/her 9.              
                Communicating physical needs such
as aches and pains 10.                         
Having a spontaneous conversation 11.             
             Responding to or communicating
anything (including yes or no) without
words 12.                          Starting a
conversation with people who are not close
family 13.                          Understanding
writing 14.                          Being a part
of a conversation when it is fast and there are a
number of people involved 15.                     
     Participating in a conversation with
strangers 16.                          Describing
or discussing something at length