Physical Exam: Lights On?

October 31, 2007

OK, before we head to the neck, I need to make a trip back upstairs - to see if there is anybody home.

Yes, it is time for the mental status exam.  This is actually often overlooked by many physicians as a normal part of the exam.  We use it in both adult and pediatric medicine on nearly every visit.  While it does earn notation on many visits, often it gets only a notation simply for billing purposes.  The way it is noted in the exam is usually this:

Gen:  Alert, NAD

This means that the person is alert in their mental processes and that they are not real sick-looking (No apparent/acute distress).  This is more important that it looks.

Distress

The term distress has a different connotation in medicine.  It is not the emotional state of the patient, but rather the emotional state that patient evokes in the doctor.  If I worry about this patient because they are close to requiring emergency intervention, then they are in distress.  If I run to their room with oxygen and/or a code cart, then they are in severe distress.

One of the crucial decisions a physician makes when encountering a patient is: how sick is this person?  With pediatrics, I very much depend on how kids look to determine my aggressiveness of therapy - especially in children under five years of age.  Kids are not nearly as likely to put on a show of illness as adults.  If a child is running around and looking well, then chances are that they won’t be admitted to the hospital.  This is not a 100% rule, but it is a 99.9% rule.  Conversely, if a child is floppy and weak-appearing, I may at times admit the child even if I don’t have anything else to go by.  Pediatricians use the expression, "the child looks sick" to mean, "I am worried that there is something more serious going on." 

Since adults have the ability to either be sicker than they look (by "acting tough") or to put on an act of being sick when they aren’t (by "being squirrely"), you cannot put nearly as much stock in the general impression when walking into a room.  If you know the patient well, however, you can draw contrasts to how they have looked in the past.

Here are some areas to consider on the general exam:

Parental/Family anxiety

How much I trust this aspect of the situation depends on how well I know the parent/family.  If this is the fourth child of a parent I know well, I will be quicker to worry than if it is their first.  If this is a parent who I know to be cool and collected, then I will worry more than if it is their first. 

This isn’t always the case, however.  I had a child who was a first child, who was 2 weeks old.  I did not know the mother well, but she said that this child was just very irritable.  I did not know why, but something in her voice made me take it seriously.  I could not find anything going on, but called my partner over and he agreed that somehow the story was worrisome.  We ran a rapid RSV (for a specific respiratory virus) on the child, and it came back positive.  Since the child looked fine, we opted just to follow up closely.  On the next day, the child looked much worse and ended up going to the pediatric ICU with breathing problems. 

I would far rather trust an unnecessarily worried parent than to mistrust someone who has good intuition.  I think some doctors ignore parents’ worry to their peril.

With adults, it is not so much parental anxiety, but anxiety of family members that can raise my concern.  People saying "he’s just not acting like himself" can often be a tip-off that something more serious is going on.  On the other hand, sometimes family members have agendas or the psychologic pathology resides in them rather than the patient.  You just have to weight all facts.

Respiratory distress

This is primarily the concern in children, as they are more commonly hospitalized for respiratory problems than anything else.  When walking into the room, I look to see if the child is doing the things that would indicate respiratory problems: nasal flaring, retraction of the muscles of the neck and upper chest, and use of abdominal muscles to help breathe.  This can be deceptive, as only patients who have energy to fight for breath.  If they are starting into full-fledged respiratory failure they may not be working hard. 

Adults also have similar symptoms of respiratory problems, but they are more likely to tell you they are short of breath, so you are not as dependent on physical signs as you are with young children.  Like children, however, sometimes when they are nearing respiratory failure, they may show less respiratory signs of problems than if they are not as sick.  You must rely on other findings for clues that things are not right.

Circulation

The most common cause of circulatory distress in children is dehydration from vomiting and/or diarrhea.  You can tell the child is having circulatory problems by noting pallor (paleness) to the skin in general, but especially to the lips and to the fingers and toes.  Pediatricians will check something called capillary refill to test for dehydration.  To check for this, you push on the fingernail or toenail for 5 seconds and then release.  If it takes over 2 seconds for the color to return, then the child is probably dehydrated.

For adults, circulatory problems can be from many sources.  Certainly adults can become dehydrated like children.  Additionally, adults can have "pump failure" due to either chronic problems with their heart (such as congestive failure) or acute problems (such as a myocardial infarction).  The blood pressure is a better measure of problems in adults than for children, as they cannot compensate with heart rate as well as children can.

Children and adults both will speed up their heart rate when they are having circulatory compromise.  In general, children’s bodies can improve circulation better with rapid heart rate than can adults.

Mental Status

We often think of mental status as being something relegated to the psychiatric field, but this is an extremely important thing to consider when examining an adult or a child.  This is best explained by dividing things up by age category.

Pediatric

Some have cynically called pediatric medicine "veterinary" medicine in that we have to figure out what is going on without talking to our patients.  While this is true for the younger patients, I would point out that doctors of all age groups need to be tuned to the non-verbal aspects of patients’ presentation.  Also, in children you are never misled by what they say - you deal with what is actually there in front of you.  In some ways, that makes things easier.

So when I approach a child’s mental status, there are several aspects to the exam:

• Are they irritable?  A young infant who is irritable or inconsolable is possibly significantly ill.  On the other hand, most 18-month-old children are irritable almost by definition.
• Are they too calm?  A child lying quietly without whimpering or crying when they are being examined may be a bad sign.  It is especially worrisome if the child getting blood drawn just lies there and lets the blood be drawn.  All of this depends on the age and overall appearance of the child, but quiet does not necessary equal good.
• I can generally sense autism when I walk into a room (for older children).  When I see a child chattering but never engaging others in the discussion, it raises red flags.  Most of the time I get the impression walking into the room, a quick check of the chart shows the diagnosis.  Sometimes, however, this feeling of non-contact and non-interaction is what leads to the diagnosis for the first time.  This is no substitute for a detailed developmental history, but as I practice for more years, it is more and more reliable.
• The other factor that is watched in children is the interaction of the parents with the child.  If a child is running out of control or if a child seems overly fearful of the parent, I become concerned.  Part of my job as a pediatrician is to assure the child meet their highest possible potential.  While this does not involve interfering with parental choice, there are certainly "teachable moments" for parents.

Adults

There are various aspects to the adult mental status exam.  Most exams you are simply interested in the overall physical health, and so pay attention only to whether there is distress.  A significant proportion of my visits, however, are for emotional issues, such as anxiety and depression.  There was a time when I felt that to be paid properly for these visits, I needed to do a regular physical exam.  I realized, however, that on each of these visits, I already am examining the patient in detail regarding their mental/emotional status.  So for the past few years, we have started simply noting a psych exam on the chart.  This exam includes:

• Appearance - Physically, how does the person appear.  Are they well dressed?  Are they thin and sickly-appearing?
• Speech - Is their speech pressured, quiet, slurred?
• Eye Contact  - Are they avoiding contact, or are they engaging conversation?
• Expressive Language  - Do they get off track easily?  Do you understand the content of what they are saying?
• Orientation - Do they know where/who they are?  Do they know the date?
• Alertness - Are they sleepy and difficult to arouse?  Are they hyper-alert?
• Coherence - Does their thought-process make sense?  Are they paranoid or delusional?
• Judgment/Insight - Do they seem capable of making decisions and understanding what you say to them?
• Mood - Are they happy or sad, angry or subdued?  This involves what they say
• Affect - Are they flat in appearance, glaring at you?  This is the external manifestation of mood. 
• Suicidal Ideation:  Not necessarily the thought of suicide, but the plan to do it.  Suicidal ideation is not wishing you were dead.  Most depressed people do that.  The real concern is when a person is not talking about it, but has thought up a plan as to how they will do this.

As long as I make note of this exam on visits, I can code a detailed physical exam (with the adequate number of "bullets" in the specific section).

One of the main questions people have when they are coming in for anxiety and depression is: "am I crazy?"  I usually try to tell them outright that they are not "crazy."  "Crazy" (psychotic) people:

• Come in because Elvis told them to come.
• Come in to tell me about the conspiracy of the squirrels trying to take over the world.
• Have psychic conversations with aliens.
• Don’t think they are crazy (in general).

I am not trying to make light of psychosis, but for people who are traumatized by life, it is nice to hear that they are simply responding to trauma in their life and are not "going crazy." 

Obviously I don’t tell them this if they really are psychotic. 

I once had a guy talk to me for 30 minutes about Elvis and how much he added to our country and how much meaning he gave to this man’s life.  He told me: "The whole world went to hell when Elvis died."

I was tempted to say: "No, I think just Elvis did."

But I didn’t.

(4 votes, average: 5 out of 5)

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Posted in Physical Exam