Chapter 1 The Physiatric History and Physical Examination
The physiatric history and physical examination (H&P) serves several purposes. It is the data platform from which a treatment plan is developed. It also serves as a written record that communicates to other rehabilitation and nonrehabilitation health care professionals. Finally, the H&P provides the basis for physician billing16 and serves as a medicolegal document. Physician documentation has become the critical component in inpatient rehabilitation reimbursement under prospective payment, as well as proof for continued coverage by private insurers. The scope of the physiatric H&P varies enormously depending on the setting, from the focused assessment of an isolated knee injury in an outpatient setting, to the comprehensive evaluation of a patient with traumatic brain or spinal cord injury admitted for inpatient rehabilitation. An initial evaluation is almost always more detailed and comprehensive than subsequent or follow-up evaluations. An exception would be when a patient is seen for a follow-up visit with substantial new signs or symptoms. Physicians in training tend to overassess, but with time the experienced physiatrist develops an intuition for how much detail is needed for each patient given a particular presentation and setting.
The physiatric H&P resembles the traditional format taught in medical school but with an additional emphasis on history, signs, and symptoms that affect function (performance). The physiatric H&P also identifies those systems not affected that might be used for compensation.22 Familiarity with the 1980 and 1997 World Health Organization classifications is invaluable in understanding the philosophic framework for viewing the evaluation of persons with physical and cognitive disabilities (Table 1-1).76,77 Identifying and treating the primary impairments to maximize performance becomes the primary thrust of physiatric evaluation and treatment.
Table 1-1 World Health Organization Definitions
| Term | Definition |
|---|---|
| 1980 | |
| Impairment | Any loss or abnormality of psychologic, physiologic, or anatomic structure or function |
| Disability | Any restriction or lack resulting from an impairment of the ability to perform an activity in the manner or within the range considered normal for a human being |
| Handicap | A disadvantage for a given individual, resulting from an impairment or a disability, that limits or prevents the fulfilment of a role that is normal for that individual |
| 1997 | |
| Impairment | Any loss or abnormality of body structure or of a physiologic or psychologic function (essentially unchanged from the 1980 definition) |
| Activity | The nature and extent of functioning at the level of the person |
| Participation | The nature and extent of a person’s involvement in life situations in relationship to impairments, activities, health conditions, and contextual factors |
From World Health Organization 198076 and 1997,77 with permission of the World Health Organization.
The exact structure of the physiatric assessment is determined in part by personal preference, training background, and institutional requirements (physician billing compliance expectations, forms committees, and regulatory oversight). The use of templates can be invaluable in maximizing the thoroughness of data collection and minimizing documentation time. Pertinent radiologic and laboratory findings should be clearly documented. The essential elements of the physiatric H&P are summarized in Table 1-2. Assessment of some or all of these elements is required for a complete understanding of the patient’s state of health and the illness for which he or she is being seen. These elements also form the basis for a treatment plan.
Table 1-2 Essential Elements of the Physiatric History and Physical Examination
| Component | Examples |
|---|---|
| Chief complaint | |
| History of present illness | Exploring location, onset, quality, context, severity, duration, modifying factors, and associated signs and symptoms |
| Functional history | Mobility: Bed mobility, transfers, wheelchair mobility, ambulation, driving, and devices required Activities of daily living: Bathing, toileting, dressing, eating, hygiene and grooming, etc. Instrumental activities of daily living: Meal preparation, laundry, telephone use, home maintenance, pet care, etc. Cognition Communication |
| Past medical and surgical history | Specific conditions: Cardiopulmonary, musculoskeletal, neurologic, and rheumatologic Medications |
| Social history | Home environment and living circumstances, family and friends support system, substance abuse, sexual history, vocational activities, finances, recreational activities, psychosocial history (mood disorders), spirituality, and litigation |
| Family history | |
| Review of systems | |
| General Medical Physical Examination | |
| Cardiac Pulmonary Abdominal Other |
|
| Neurologic Physical Examination | |
| Level of consciousness Attention Orientation Memory General fund of knowledge Abstract thinking Insight and judgment Mood and affect |
|
| Communication | |
| Cranial nerve examination | |
| Sensation | |
| Motor control | Strength Coordination Apraxia Involuntary movements Tone |
| Reflexes | Superficial Deep Primitive |
| Musculoskeletal Physical Examination | |
| Inspection | Behavior Physical symmetry, joint deformity, etc. |
| Palpation | Joint stability Range of motion (active and passive) Strength testing (see above) Painful joints and muscles |
| Joint-specific provocative maneuvers |
An emergence in the use of electronic medical records (EMR) has significantly altered the landscape for documentation of the physiatric H&P in both the inpatient and outpatients settings.23 Among the advantages of the EMR are increased legibility, time efficiency afforded by the use of templates and “smart phrases” that can be tailored to individual practitioners, and automated warnings regarding medication interactions or errors, as well as faster and more accurate billing. Disadvantages include overuse of the “copy and paste” function, leading to the appearance of redundancy among consecutive notes and the perpetuation of potentially inaccurate information, automated importation of data not necessarily reviewed by the practitioner at the time of service, and “alarm fatigue.” As regulation of hospital and physician practice and billing increases, the EMR will become more important in ensuring the proper, and sometimes convoluted, documentation required for safety initiatives40 and physician payment.15
The Physiatric History
The time spent in taking a history also allows the patient to become familiar with the physician, establishing rapport and trust. This initial rapport is critical for a constructive and productive doctor–patient–family relationship and can also help the physician learn about such sensitive areas as the sexual history and substance abuse. It can also have an impact on outcome, as a trusting patient tends to be a more compliant patient.62 Assessing the tone of the patient and/or family (such as anger, frustration, resolve, and determination), understanding of the illness, insight into disability, and coping skills are also gleaned during history taking. In most cases, the patient leads the physician to a diagnosis and conclusion. In other cases, such as when the patient is rambling and disorganized, frequent redirection and refocus are required.
History of the Present Illness
The history of the present illness (HPI) details the chief complaint(s) for which the patient is seeking medical attention, as well as any related or unrelated functional deficits. It should also explore other information relating to the chief complaint such as recent and past medical or surgical procedures, complications of treatment, and potential restrictions or precautions. The HPI should include some or all of eight components related to the chief complaint: location, time of onset, quality, context, severity, duration, modifying factors, and associated signs and symptoms (see Table 1-2).
Functional Status
Assessing the potential for functional gain or deterioration requires an understanding of the natural history, cause, and time of onset of the functional problems. For example, most spontaneous motor recovery after stroke occurs within 3 months of the event.68 For a recent stroke patient with considerable motor impairments, there is a greater expectation for significant functional gain than in a patient with minor deficits related to a stroke that occurred 2 years ago.
It is sometimes helpful to assess functional status using a standardized scale. No single scale is appropriate for all patients, but the Functional Independence Measure (FIM) is the most commonly used in the inpatient rehabilitation setting (Table 1-3; see Chapter 8).3 Measuring only activity limitation (disability) or performance, each of 18 different activities is scored on a scale of 1 to 7, with a score of 7 indicating complete independence. Intermediate scores indicate varying levels of assistance from very little (from an assistive device, to supervision, to hands-on assistance) to a score of 1 indicating complete dependence on caregiver assistance. FIM scores also serve as a kind of rehabilitation shorthand among team members to quickly and accurately describe functional deficits.
Table 1-3 Levels of Function on the Functional Independence Measure
| Level of Function | Score | Definition |
|---|---|---|
| Independent |
From Anonymous3 1997, with permission of the State University of New York at Buffalo.
Mobility
Mobility is the ability to move about in one’s environment and is taken for granted by most healthy people. Because it plays such a vital role in society, any impairment related to mobility can have major consequences for a patient’s quality of life. A clear understanding of the patient’s functional mobility is needed to determine independence and safety, including the use of, or need for, mobility assistive devices. There is a range of mobility assistive devices that patients can use, such as crutches, canes, walkers, orthoses, and manual and electric wheelchairs (Table 1-4; see Chapters 15 and 17).
| Category | Example |
|---|---|
| Crutches |
Driving is a crucial activity for many people, not only as a means of transportation but also as an indicator and facilitator of independence. For example, elders who stop driving have an increase in depressive symptoms.50 It is important to identify factors that might prevent driving, such as decreased cognitive function and safety awareness, and decreased vision or reaction time. Other factors affecting driving can include lower limb weakness, contracture, tone, or dyscoordination. Some of these conditions might require use of adaptive hand controls for driving. Cognitive impairment sufficient to affect the ability to drive can be due to medications or organic disease (dementia, brain injury, stroke, or severe mood disturbance). Ultimately, the risks of driving are weighed against the consequences of not being able to drive. If the patient is no longer able to drive, alternatives to driving should be explored, such as the use of public or assisted transportation. Laws differ widely from state to state on the return to driving after a neurologic impairment develops.
Activities of Daily Living and Instrumental Activities of Daily Living
ADL encompass activities required for personal care including feeding, dressing, grooming, bathing, and toileting. I-ADL encompass more complex tasks required for independent living in the immediate environment such as care of others in the household, telephone use, meal preparation, house cleaning, laundry, and in some cases use of public transportation. In the Occupational Therapy Practice Framework, there are 11 activities for both ADL and I-ADL (Box 1-1).4
BOX 1-1 Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (I-ADL)
Modified from [Anonymous]: Occupational Therapy Practice Framework: domain and process. Am J Occup Ther 56:609-639, 2002 (Erratum in: Am J Occup Ther 2003; 57:115) with permission.
The clinician should identify and document ADL the patient can and cannot perform, and determine the causes of limitation. For example, a woman with a stroke might state that she cannot put on her pants. This could be due to a combination of factors such as a visual field cut, balance problems, weakness, pain, contracture, hypertonia, or deficits in motor planning. Some of these factors can be confirmed later in the physical examination. A more detailed follow-up to a positive response to the question is frequently needed. For example, a patient might say “yes” to the question “Can you eat by yourself?” On further questioning, it might be learned that she cannot prepare the food by herself or cut the food independently. The most accurate assessment of ADL and mobility deficits often comes from the hands-on assessment by therapists and nurses on the rehabilitation team.
Cognition
Cognition is the mental process of knowing (see Chapters 3 and 4). Although objective assessment of cognition comes under physical examination (memory, orientation, and the ability to assimilate and manipulate information), impairments in cognition can also become apparent during the course of the history taking. Because persons with cognitive deficits often cannot recognize their own impairments (anagnosia), it is important to gather information from family members and others familiar with the patient. Cognitive deficits and limited awareness of these deficits are likely to interfere with the patient’s rehabilitation program unless specifically addressed. These deficits can pose a safety risk as well. For example, a man with a previous stroke who falls, sustaining a hip fracture requiring replacement, might not be able to follow hip precautions, resulting in possible refracture or hip dislocation. Executive functioning is another aspect of cognition, which includes the mental functions required for planning, problem solving, and self-awareness. Executive functioning correlates with functional outcome because it is required in many real-world situations.45
Past Medical and Surgical History
Musculoskeletal
There can be a wide range of musculoskeletal disorders from acute traumatic injuries to gradual functional decline with chronic osteoarthritis. The patient should be asked about a history of trauma, arthritis, amputation, joint contractures, musculoskeletal pain, congenital or acquired muscular problems, weakness, or instability. It is important to understand the functional impact of such impairments or disabilities. Patients with chronic physical disability often develop overuse musculoskeletal syndromes, such as the development of shoulder pain secondary to chronically propelling a wheelchair.33
Rheumatologic
The history should assess the type of rheumatologic disorder, time of onset, number of joints affected, pain level, current disease activity, and past orthopedic procedures. Discussions with the patient’s rheumatologist might address whether medication changes could improve activity tolerance in a rehabilitation program (see Chapter 36).
Medications
All medications should be documented including prescription and over-the-counter drugs, as well as nutraceuticals, supplements, herbs, and vitamins. Medications should be documented from both the last institutional venues (acute care, nursing home) and from home before institutionalization. Decreasing medication errors via medication reconciliation is a major thrust of the National Patient Safety Goals initiative.40 Patients typically do not mention medications that they do not think are relevant to their current problem, unless asked about them in detail. Drug and food allergies should be noted. It is especially important to gather the complete list of medications being used in patients who are seeing multiple physicians. Particular attention should be paid to nonsteroidal antiinflammatory agents because these are commonly prescribed by physiatrists for musculoskeletal disorders, and care must be taken not to double-dose the patient.27,32 The indications, precautions, and side effects of all drugs prescribed should be explained to the patient.
Social History
Substance Abuse
Patients should be asked about their history of smoking, alcohol use or abuse, and drug abuse. Because patients often deny substance abuse, this topic should be discussed in a nonjudgmental manner. Patients frequently feel embarrassment or guilt in admitting substance abuse, and also fear the legal consequences of such an admission. Substance abuse can be a direct and an indirect cause of disability, and is often a contributing factor in traumatic brain injury.19 It can also have an impact on community reintegration, because patients with pain and/or depression are at risk for further abuse. Patients who are at risk should be referred to social work to explore options for further assistance, either during the acute rehabilitation or later in the community.
Sexual History
Patients and health care practitioners alike are often uncomfortable discussing the topic of sexuality, so developing a good rapport during history taking can be helpful. Discussion of this topic is made easier if the health care practitioner has a basic knowledge of how sexual function can be changed by illness or injury (see Chapter 31). Sexuality is particularly important to patients in their reproductive years (such as with many spinal cord– and brain-injured persons), but the physician should enquire about sexuality in adolescents and adults, as well as in the elderly. Sexual orientation and safer sex practices should be addressed when appropriate.
Spirituality and Belief
Spirituality is an important part of the lives of many patients, and some preliminary studies indicate that it can have positive effects on rehabilitation, life satisfaction, and quality of life.13 Health care providers should be sensitive to the patient’s spiritual needs, and appropriate referral or counseling should be provided.17
Pending Litigation
Patients should be asked in a nonjudgmental fashion whether they are involved in litigation related to their illness, injuries, or functional impairment. The answer should not change the treatment plan, but litigation can be a source of anxiety, depression, or guilt. In some cases the patient’s legal representative can play an important role in obtaining needed services and equipment.
Review of Systems
A detailed review of organ systems should be done discover any problems or diseases not previously identified during the course of the history taking. Table 1-5 lists some questions that can be asked about each system.24 Note that this list is not comprehensive, and more detailed questioning might be necessary.
| System | Questions |
|---|---|
| Systemic | Any general symptoms such as fever, weight loss, fatigue, nausea, and poor appetite? |
| Skin | Any skin problems? Sores? Rashes? Growths? Itching? Changes in the hair or nails? Dryness? |
| Eyes | Any changes in vision? Pain? Redness? Double vision? Watery eyes? Dizziness? |
| Ears | How are the ears and hearing? Running ears? Poor hearing? Ringing ears? Discharge? |
| Nose | How are your nose and sinuses? Stuffy nose? Discharge? Bleeding? Unusual odors? |
| Mouth | Any problems with your mouth? Sores? Bad taste? Sore tongue? Gum trouble? |
| Throat and neck | Any problems with your throat and neck? Sore throat? Hoarseness? Swelling? Swallowing? |
| Breasts | Any problems with your breasts? Lumps? Nipple discharge? Bleeding? Swelling? Tenderness? |
| Pulmonary | Any problems with your lungs or breathing? Cough? Sputum? Bloody sputum? Pain in the chest on taking a deep breath? Shortness of breath? |
| Cardiovascular | Do you have any problems with your heart? Chest pain? Shortness of breath? Palpitations? Cough? Swelling of your ankles? Trouble lying flat in bed at night? Fatigue? |
| Gastrointestinal | How is your digestion? Any changes in your appetite? Nausea? Vomiting? Diarrhea? Constipation? Changes in your bowel habits? Bleeding from the rectum? Hemorrhoids? |
| Genitourinary | Male: Any problems with your kidneys or urination? Painful urination? Frequency? Urgency? Nocturia? |
| Bloody or cloudy urine? Trouble starting or stopping? | |
| Female: Number of pregnancies? Abortions? Miscarriages? Any menstrual problems? Last menstrual period? Vaginal bleeding? Vaginal discharge? Cessation of periods? Hot flashes? Vaginal itching? Sexual dysfunction? | |
| Endocrine | Any problems with your endocrine glands? Feeling hot or cold? Fatigue? Changes in the skin or hair? Frequent urination? Fatigue? |
| Musculoskeletal | Do you have any problems with your bones or joints? Joint or muscle pain? Stiffness? Limitation of motion? |
| Nervous system | Numbness? Weakness? Pins and needles sensation? |
From Enelow AJ, Forde DL, Brummel-Smith K: Interviewing and patient care, ed 4, New York, 1996, Oxford University Press,24 with permission of Oxford University Press.
The Physiatric Physical Examination
Neurologic Examination
Weakness is a primary sign in neurologic disorders and is seen in both upper (UMN) and lower motor neuron (LMN) disorders. UMN lesions involving the central nervous system (CNS) are typically characterized by hypertonia, weakness, and hyperreflexia without significant muscle atrophy, fasciculation, or fibrillation (on electromyography). They tend to occur in a hemiparetic, paraparetic, and tetraparetic pattern. UMN etiologies include stroke, multiple sclerosis, traumatic and nontraumatic brain and spinal cord injuries, and neurologic cancers, among others. LMN defects are characterized by hypotonia, weakness, hyporeflexia, significant muscle atrophy, fasciculations, and electromyographic changes. They occur in the distribution of the affected nerve root, peripheral nerve, or muscle. UMN and LMN lesions often coexist; however, the LMN system is the final common pathway of the nervous system. An example of this is an upper trunk brachial plexus injury on the same side as spastic hemiparesis in a person with traumatic brain injury.51
Similar to physical examination in other organ systems, testing of one neurologic system is often predicated by the normal functioning of other systems. For example, severe visual impairment can be confused with cerebellar dysfunction, as many cerebellar tests have a visual component. The integrated functions of all organ systems should be considered to provide an accurate clinical assessment, and potential limitations of the examination should be considered.
Mental Status Examination
The mental status examination (MSE) should be performed in a comfortable setting where the patient is not likely to be disturbed by external stimuli such as televisions, telephones, pagers, conversation, or medical alarms. The bedside MSE is often limited secondary to distractions from within the room. Having a familiar person such as a spouse or relative in the room can often help reassure the patient. The bedside MSE might need to be supplemented by far more detailed and standardized evaluations performed by neuropsychologists, especially in cases of vocational and educational reintegration (see Chapters 4 and 35). Language is the gateway to assessing cognition and is therefore limited in persons with significant aphasia.
Level of Consciousness
The examiner should understand the various levels of consciousness. Lethargy is the general slowing of motor processes (such as speech and movement) in which the patient can easily fall asleep if not stimulated, but is easily aroused. Obtundation is a dulled or blunted sensitivity in which the patient is difficult to arouse, and once aroused is still confused. Stupor is a state of semiconsciousness characterized by arousal only by intense stimuli such as sharp pressure over a bony prominence (e.g., sternal rub), and the patient has few or even no voluntary motor responses.56 The Aspen Neurobehavioral Conference proposed, and several leading medical organizations have endorsed, three terms to describe severe alterations in consciousness.29 In coma, the eyes are closed with absence of sleep-wake cycles and no evidence of a contingent relationship between the patient’s behavior and the environment.29 Vegetative state is characterized by the presence of sleep-wake cycles but still no contingent relationship. Minimally conscious state indicates a patient who remains severely disabled but demonstrates sleep-wake cycles and even inconsistent, nonreflexive, contingent behaviors in response to a specific environmental stimulation. In the acute settings, the Glasgow Coma Scale is the most often used objective measure to document level of consciousness, assessing eye opening, motor response, and verbal response (Table 1-6).39
| Function | Rating |
|---|---|
| Eye opening | E |
| Spontaneous | 4 |
| To speech | 3 |
| To pain | 2 |
| Nil | 1 |
| Best motor response | M |
| Obeys | 6 |
| Localizes | 5 |
| Withdraws | 4 |
| Abnormal flexion | 3 |
| Extensor response | 2 |
| Nil | 1 |
| Verbal response | V |
| Oriented | 5 |
| Confused conversation | 4 |
| Inappropriate words | 3 |
| Incomprehensible sounds | 2 |
| Nil | 1 |
| Coma score (E + M + V) | 3-15 |
From Jennett B, Teasdale G: Assessment of impaired consciousness, Contemp Neurosurg 20:78, 1981 with permission.
Attention
Attention is the ability to address a specific stimulus for a short period without being distracted by internal or external stimuli.65 Vigilance is the ability to hold attention over longer periods. For example, with inadequate vigilance a patient can begin a complex task but be unable to sustain performance to completion. Attention is tested by digit recall, where the examiner reads a list of random numbers and the patient is asked to repeat those numbers. The patient should repeat digits both forward and backward. A normal performance is repeating seven numbers in the forward direction, with fewer than five indicating significant attention deficits.52,65
Orientation
Orientation is necessary for basic cognition. Orientation is composed of four parts: person, place, time, and situation. After asking the patient’s name, place can be determined by asking the location the patient is currently in or her or his home address. Time is assessed by asking the patient the time of day, the date, the day of the week, or the year. Situation refers to why the patient is in the hospital or clinic. Time sense is usually the first component lost, and person is typically the last to be lost. Temporary stress can account for a minor loss of orientation; however, major disorientation usually suggests an organic brain syndrome.69
Memory
The components of memory include learning, retention, and recall. During the bedside examination, the patient is typically asked to remember three or four objects or words. The patient is then asked to repeat the items immediately to assess immediate acquisition (encoding) of the information. Retention is assessed by recall after a delayed interval, usually 5 to 10 minutes. If the patient is unable to recall the words or objects, the examiner can provide a prompt (e.g., “It is a type of flower” for the word “tulip”). If the patient still cannot recall the words or objects, the examiner can provide a list from which the patient can choose (e.g., “Was it a rose, a tulip, or a daisy?”). Although abnormal scores must be interpreted within the context of the remaining neurologic examination, normal individuals younger than 60 years should recall three of four items.65
Recent memory can also be tested by asking questions about the past 24 hours, such as “How did you travel here?” or “What did you eat for breakfast this morning?” Assuming the information can be confirmed, remote memory is tested by asking where the patient was born or the school or college attended.46 Visual memory can be tested by having the patient identify (after a few minutes) four or five objects hidden in clear view.
Abstract Thinking
Abstraction is a higher cortical function and can be tested by the interpretation of common proverbs such as “a stitch in time saves nine” or “when the cat’s away the mice will play,” or by asking similarities, such as “How are an apple and an orange alike?” A concrete explanation for the first proverb would be “You should sew a rip before it becomes bigger,” whereas an abstract explanation would be “Quick attention to a given problem would prevent bigger troubles later.” An abstract response to the similarity would be “They are both kinds of fruit,” and a concrete response would be “They are both round” or “You can eat them both.” Most normal individuals should be able to provide abstract responses. A patient also demonstrates abstraction when he or she understands a humorous phrase or situation. Concrete responses are given by persons with dementia, mental retardation, or limited education. Abstract thinking should always be considered in the context of intelligence and cultural differences.69
Insight and Judgment
Insight has been conceptualized into three components: awareness of impairment, need for treatment, and attribution of symptoms. Insight can be ascertained by asking what brought the patient into the hospital or clinic.10 Recognizing that one has an impairment is the initial step for recovery. A lack of insight can severely hamper a patient’s progress in rehabilitation and is a major consideration in developing a safe discharge plan. Insight can be difficult to distinguish from psychological denial.
Judgment is an estimate of a person’s ability to solve real-life problems. The best indicator is usually simply observing the patient’s behavior. Judgment can also be assessed by noting the patient’s responses to hypothetical situations in relation to family, employment, or personal life. Hypothetical examples of judgment that reflect societal norms include “What should you do if you find a stamped, addressed envelope?” or “How are you going to get around the house if you have trouble walking?” Judgment is a complex function that is part of the maturational process and is consequently unreliable in children and variable in the adolescent years.69 Assessment of judgment is important to assess the patient’s capacity for independent functioning.
Mood and Affect
Mood can be assessed by asking the “Yale question”: “Do you often feel sad or depressed?”72 Establishing accurate information pertaining to the length of a particular mood is important. The examiner should document if the mood has been reactive (e.g., sadness in response to a recent disabling event or loss of independence), and whether the mood has been stable or unstable. Mood can be described in terms of being, including happy, sad, euphoric, blue, depressed, angry, or anxious.
Affect describes how a patient feels at a given moment, which can be described by terms such as blunted, flat, inappropriate, labile, optimistic, or pessimistic. It can be difficult to accurately assess mood in the setting of moderate to severe acquired brain injury. A patient’s affect is determined by the observations made by the examiner during the interview.11
General Mental Status Assessment
The Folstein Mini-Mental Status Examination is a brief and convenient tool to test general cognitive function. It is useful for screening patients for dementia and brain injuries. Of a maximum 30 points, a score 24 or above is considered within the normal range.25 Also available is the easily administered Montreal Cognitive Assessment.54 The clock-drawing test is another quick test sensitive to cognitive impairment. The patient is instructed to “Without looking at your watch, draw the face of a clock, and mark the hands to show 10 minutes to 11 o’clock.” This task uses memory, visual spatial skills, and executive functioning. The drawing is scored on the basis of whether the clock numbers are generally intact or not intact out of a maximum score of 10.66 The use of the three-word recall test in addition to the clock-drawing test, which is known collectively as the Mini-Cog Test, has recently gained popularity in screening for dementia. The Mini-Cog can usually be completed within 2 to 3 minutes.60 The reader is referred to other excellent descriptions of the MSE for further reading.65
Communication
Aphasia
Aphasia involves the loss of production or comprehension of language. The cortical center for language resides in the dominant hemisphere. Naming, repetition, comprehension, and fluency are the key components of the physician’s bedside language assessment. The examiner should listen to the content and fluency of speech. Testing of comprehension of spoken language should begin with single words, progress to sentences that require only yes–no responses, and then progress to complex commands. The examiner should also assess visual naming, repetition of single words and sentences, word-finding abilities, and reading and writing from dictation and then spontaneously. Circumlocutions are phrases or sentences substituted for a word the person cannot express, such as responding “What you tell time with on your wrist” when asked to name a watch. Alexia without agraphia is seen in dominant occipital lobe injury. Here the patient is able to write letters and words from a spoken command but is unable to read the information after dictation.12 Some commonly used standardized aphasia measures include the Boston Diagnostic Aphasia Examination and the Western Aphasia Battery (see Chapter 3).67
Dysarthria
Dysarthria refers to defective articulation, but with the content of speech unaffected. The examiner should listen to spontaneous speech and then ask the patient to read aloud. Key sounds that can be tested include “ta ta ta,” which is made by the tongue (lingual consonants); “mm mm mm,” which is made by the lips (labial consonants); and “ga ga ga,” which is made by the larynx, pharynx, and palate.46 There are several subtypes of dysarthria including spastic, ataxic, hypokinetic, hyperkinetic, and flaccid.52
Dysphonia
Dysphonia is a deficit in sound production and can be secondary to respiratory disease, fatigue, or vocal cord paralysis. The best method to examine the vocal cords is by indirect laryngoscopy. Asking the patient to say “ah” while viewing the vocal cords is used to assess vocal cord abduction. When the patient says “e,” the vocal cords will adduct. Patients with weakness of both vocal cords will speak in whispers with the presence of inspiratory stridors.46
Verbal Apraxia
Apraxia of speech involves a deficit in motor planning (i.e., awkward and imprecise articulation in the absence of impaired strength or coordination of the motor system). It is characterized by inconsistent errors when speaking. A difficult word might be spoken correctly, but trouble is experienced when repeating it. People with verbal apraxia of speech often appear to be “groping” for the right sound or word, and might try to speak a word several times before saying it correctly. Apraxia is tested by asking the patient to repeat words with an increasing number of syllables. Oromotor apraxia is seen in patients with difficulty organizing nonspeech, oral motor activity. This can adversely impact swallowing. Tests for oromotor apraxia include asking patients to stick out their tongue, show their teeth, blow out their cheeks, or pretend to blow out a match.1
