Ax Flashcards
What to do prior to Subjective Ax
Consent and address yourself, check patient name and details.
What to check in PC and HPC
PC: Problems - impairment, activity, participation
HPC: How long they have had neurological disease - is it progressing/worsening, previous treatment - did it work or make it worse
What to ask/check in PMH
Systems:
- Neurological – any previous strokes, any other neurological event
- MSK – OA/RA, osteoporosis, fractures, soft tissue injuries, pain anywhere
- Respiratory – Chronic – COPD (CB, Emphysema), Asthma; Acute – pneumonia, surgery
- Cardiovascular – MI, CCF, surgery
- Urinary – kidney disease
- Endocrine - DDM
What to ask/check in DH
Condition specific:
PD – dopamine agonists - Madopar and Sinemet
CVA – anti-platelets (Clopidogrel) , anti-coagulants, cholesterol-reducing statins (Atorvastatin), BP medication, antispasmodics
MS – antispasmodics (Baclofen and Tinazadine), anti-inflammatories
TBI – antispasmodics (Baclofen and Tinazadine)
SCI – antispasmodics (Baclofen and Tinazadine)
What to check/ask in SH
5 main topics:
- Home – a bungalow, stairs, any equipment in place
- Support – patient have dependents; own support network
- Work – progressive disease (honesty to RTW), will they be able to get back to the same job?; goal setting
- Hobbies – achievable? Goal setting
- Mobility – previous mobility in ADLs (PADLs, DADLs)
What SQs to ask
- Falls – how many falls in past 6 months, during what activities, dizziness, did they lose consciousness? Did they hurt themselves? Are they worries about falling again - Falls Efficacy Scale (FES-1)
- Fatigue – Measured via Fatigue specific Outcome Measures i.e Fatigue Impact Scale. What makes it worse? What makes it better? Are they sleeping? How is their diet? Do they feel stressed? Do they exercise?
- Pain – do they have any pain? Where is it? Type of pain? SIN? Use a pain rating scale – NPRS.
What can you learn as you talk to the patient
- Communication -Hearing (hearing aids), Sight (glasses), Speech (receptive/expressive dysphasia), agnosia, Cognition, language barrier
- Consciousness – AVPU, GCS, AAOx3 – name, location, day/time
- Confusion level
- Emotional status
- Fatigue - able to establish how assessment/ treatment needs to be moderated according to this.
- Goals (why is this important? Every patient has individual needs – rehab must always be in their best interest)
What are you learning from Observation
Postural alignment in static/dynamic postures, movement patterns, compensations
What are you learning from AROM
Strength (3/5 oxford scale = AROM against gravity), quality of movement (smooth/co-ordinated/well-timed/effortless), involuntary movements, pain, range (estimate or measure if only one joint),
What are you learning from PROM
Is the joint limiting movement, what is the end range feel, Pain/ bony block/ stiffness/ contracture/ tone assessment, sensory awareness, anxious (facial expression)
What are the two different types of special testing
Sensory testing – tests sensory system, damage can happen anywhere along this pathway – sensory receptor, peripheral nerve, spinal cord, brainstem, thalamus, sensory cortex
Co-ordination testing – tests for cerebellum damage resulting in ataxia: can get truncal or appendicular ataxia or both depending on area of cerebellar damage. Appendicular ataxia is usually caused by lesions of the cerebellar hemispheres and associated pathways. Truncal ataxia is often caused by damage to the midline cerebellar vermis and associated pathways
What are sensory tests
Proprioceptive
Sharp/blunt
Two-point discrimination
Light/Deep touch
Stereognosis
Hot and Cold
Proprioception (demonstrate and describe how to do
this test)
Patients eyes closed; Moving one of the patient’s fingers or toes up and down and asking the patient to report which way it moves. Hold the digit lightly by the sides while doing this so that tactile inputs don’t provide significant clues to the direction of movement. The digit should be moved very slightly because normal individuals can detect movements that are barely perceptible by eye
Considerations:
UL: hand on elbow - support GH
LL: hand on knee - support leg
Sharp/blunt (demonstrate and describe how to do this test) –
Patients eyes closed; place sharp or blunt side on equal aspects of their non-affected side followed by affected side asking patient to report if it is sharp or blunt. Move in dermatomal fashion
Two-point discrimination (demonstrate and describe how to do this test)
Special pair of calipers, or a bent paper clip, alternating randomly between touching the patient with one or both points. The minimal separation (in mm) at which the patient can distinguish these stimuli should be recorded in each extremity.
Normal = distinguish 2-points at 3-4mm
Used for patients goal - work with finger mobility
Light/deep touch (demonstrate and describe how to do this test)
Light touch is best tested with a cotton-tipped swab, but a light finger touch will often suffice, as long as care is taken to make the stimulus fairly reproducible.
You can test the relative sharpness of pain by randomly alternating stimuli with the sharp or dull end of a safety pin (always use a new pin for each patient).
Stereognosis (demonstrate and describe how to do this test
Ask the patient to close their eyes and identify various objects by touch using one hand at a time
- Cannot reliably be tested for unless primary sensation is intact bilaterally
- Also a cognitive test - for cognitive deficit – expressive/receptive dysphasia
Hot and cold (demonstrate and describe how to do this test
Tested with a cool piece of metal such as a tuning fork
- FTN (demonstrate and describe how to do this test)
Patient is asked to alternately touch their nose and the examiner’s finger as quickly as possible
Ataxia is best revealed if the examiner’s finger is held at the extreme of the patient’s reach, and if the examiner’s finger is occasionally moved suddenly to a different location
HTS (demonstrate and describe how to do this test)
Sit next to patient to support; patient is asked to touch the heel of one foot to the opposite knee and then to drag their heel in a straight line all the way down the front of their shin and back up again. In order to eliminate the effect of gravity in moving the heel down the shin, this test should always be done in the supine position.
Rapid movements (demonstrate and describe how to do this test
UL: wiping one palm alternately with the palm and dorsum of the other hand
LL: sitting down patient lifts foot up and down
Test Dysdiadochokinesia (DDK) - difficulty performing quick and alternating movements, usually by opposing muscle groups; PD patients will struggle as they move slowly
Which reflexes can you test?
- Biceps (elbow flexion)
- Brachioradialis (Elbow pronation)
- Triceps (elbow extension)
- Quadriceps (knee extension)
- TA (ankle plantarflexion)
- Babinski (UMNL)
List the functional assessments you would need to assess
- Rolling
- Lie to sit
- Sitting balance
- Sit to stand
- Standing balance
- Mobility + gait
- Stair climbing
- UL function – ADLs (PADLs, DADLs)
OMs
Pain – NPRS, VAS
Falls – FES/-1, ABC, Confbal, Yardley Fear of Falling Qs, VAS
ROM – goniometer, Hudl
Strength – Oxford scale, HHD
Sensation – Fugl-meyer, Nottingham sensory assessment with Erasmus modifications (EmNSA)
Coordination – 9-hole peg test, SARA
Tone – Modified Ashworth Scale, PROM/AROM
Standing balance – 180 turn/TUSS/GUAG/BBS/POMA (Tinetti)
Gait – 10m/6m/3m/ISWT/6MWT
UL function – videos or timed PADLs, DADLs
Trunk stability – TIS, PASS
Who are the other members of the MDT team
- Doctors (Consultant, Registrar, Core Trainee Specialty Training, Trust Grade, Foundation Year 1 &2)
- Pharmacists
- Occupational Therapists (OTs)
- Therapy assistants
- Nursing staff
- Health care assistants
- Speech and Language Therapists (SALTs)
- Dieticians
- Psychologists
- Social workers
- Orthotists
What is the role of doctors
To diagnose, treat and manage patients medical plan including decision making with regards to active care, palliative or end of life care
What is the role of pharmacists
Managing medication doses and interactions, prescribing and assisting medical team with subscribing medication, communication with patients surrounding management of medication
What is the role of OTs and therapy assistants
OTs:
Assessment of physical, sensory, cognitive problems in functional activities in order to assist rehabilitation / address barriers affecting emotional/ social/ physical needs/ May be specialists in: Equipment/ adaptation assessment, splinting, seating/ postural management equipment, cognitive assessment
Therapy assistants:
Assisting therapy staff with assessment and treatment
What is the role of nursing staff and health care assistants
Nursing staff:
Medication administration, management of plan for continence, skin/ pressure management, caring for physical needs of patient, taking regular observations of patient, depending on speciality: ITU/ clinic nurse/ ward nurse/ community nursing/ school nurse – will include wide variety of roles and responsibilities
Health care assistants:
Assisting nursing staff with practical care of patients
What is the role of SALTs
Assessment and management of people experiencing communication, swallowing, eating and drinking difficulties or support/ treatment for people experiencing cognitive/ psychological problems with speaking and communicating
What is the role of dieticians
Assessment and treatment around assisting individuals with dietary advise, planning, nutrition advise and treatment
What is the role of the psychologists
Assessment and treatment for behavioural, emotional and psychological problems, counselling, CBT, lifestyle advise and assistance with social integration/ management, liaison with medical team r.e appropriate medications.
What is the role of social workers
Provide advice/ support, assists services in local community to provide appropriate care for patients, assist in decisions surrounding housing/ accommodation, level of care provided outside of hospital, discharge destination – in liaison with MDT/ patient/ family members
What is the role of the orthotists
Assessment and provision of orthotics and adaptive aids – splints, AFOs, braces, specialist footwear
