	Anxiety	Depression
Somatic	Palpitations	Altered appetite
	Tremor	Constipation
	Breathlessness	Headache
	Dizziness	Bodily fatigue
	Fatigue	Tiredness
	Diarrhoea
	Sweating
Psychic	Feelings of tension	Apathy
	Irritability	Poor concentration
	Difficulty sleeping	Early-morning waking
	Fear	Diurnal mood swing
	Depersonalisation	Retardation
		Guilt

Obsession

These are recurrent thoughts which often result in the performance of repetitive acts (compulsion). The patient is aware that they are inappropriate but cannot resist returning to them or acting upon them. Examples of obsessional thought include convictions that a particular individual is antagonistic or that a spouse is unfaithful.

ABNORMAL PERCEPTIONS

These are auditory or visual phenomena of which other individuals are not aware.

Hallucinations are experiences that have no objective equivalent to explain them. They are predominantly visual or auditory but can occur in other forms, for example, of smell or taste in patients with complex partial seizures. Visual hallucinations can be unformed, for example an ill-defined pattern of lights, or formed, the individual then describing people or animals, often of a frightening aspect. Visual hallucinations are more often a feature of an organic brain syndrome (e.g. delirium tremens or an adverse drug reaction) than a functional psychosis, e.g. schizophrenia. Auditory hallucinations are also either unformed or formed. They are found more often in the functional psychoses than in organic brain disease. The voices can take on a persecutory quality in schizophrenia and an accusatory element in depression. In déjà vu and jamais vu, intense feelings of a relived experience or a sensation of strangeness in familiar surroundings occur, respectively. Both can be a feature of everyday life but when pathological are usually epileptic. Illusions are misinterpretation of an external reality – all of us have this when watching a magician at work. In depersonalisation, the individual feels a detachment from the normal sense of self, in derealisation a detachment from the external world. Both occur in neurotic illnesses but also, periodically, in normal individuals.

The assessment of higher cortical function has already been discussed. It is necessary to distinguish cognitive impairment due to dementia, from cognitive impairment due to delirium. In the latter there is clouding of consciousness, usually manifested as reduced awareness of, or response to, the environment.

The family history

Begin by obtaining details of the patient’s father and mother, in terms of their current age (or age at death), their own quality of health, whether they had any history of psychiatric disorder and the quality of the patient’s relationship with them. Ask similar questions about the patient’s siblings. Questions regarding the patient’s own children are usually included in the personal history. Genetic factors are particularly strong in schizophrenia and manic–depressive psychosis.

The personal history

CHILDHOOD

It is unlikely that the patient will have accurate details of birth or early development unless there were particular problems with them. A direct question to the patient regarding whether he or she was happy or unhappy in childhood is useful. Some ‘happy’ responses turn out to be rather less so with further delving. If there is an expression of remembered unhappiness, explore it further in terms of relationships with parents and any physical illness.

SCHOOLING AND FURTHER EDUCATION

Establishing the details of this is helpful in forming an assessment of the patient’s premorbid intelligence. At the same time enquire about friendships or a tendency to isolation and about teasing or bullying.

SEXUAL DEVELOPMENT

For female patients, enquire about the age of the menarche and how they attuned to adolescence in terms of menstruation and sexuality. For men, discussion should include whether their sexuality could be discussed in the home and how they acquired their sexual experience. Further issues relating to sexual development, for example homosexual experiences, are best left, at this stage, to the patient to raise.

MARITAL HISTORY

An overall outline here includes the age of the spouse, when the marriage occurred, the overall quality of the relationship, the state of the sexual relationship and details of any children.

OCCUPATIONAL HISTORY

Ask how many jobs the patient has had, reasons for leaving previous posts, the quality of relationship in the work place and the level of job satisfaction. If there has been one or more periods of unemployment, explore what effect this has had on the patient’s overall welfare.

PAST MEDICAL HISTORY

This follows the usual pattern, and includes history of physical and mental illnesses if these have occurred.

DRUG HISTORY

Determine alcohol consumption, but be aware of the possibility that the figure does not correspond to actual intake. Features suggesting alcohol dependency include early-morning drinking, morning vomiting, taking a drink before an interview, erratic work attendance and drinking in isolation. Ask about narcotic exposure, the use of softer drugs such as cannabis and exposure to tranquillisers. If the patient is using codeine derivatives, ascertain for what purpose and the dosage.

PERSONALITY PROFILE

Evidence suggesting changing personality and mood is often better provided by colleagues, relatives or friends than by the patient. Questionnaires exist for the assessment of personality but even without them the patient’s attitude and behaviour, in terms of work and social relationships, personal ambitions, drive, level of independence and authority and response to stress, will indicate the patient’s maturity.

HEADACHE AND FACIAL PAIN

THE CRANIAL NERVES

Second cranial nerve (optic)

EXAMINATION

Visual acuity

• For distance vision, use a Snellen chart at 6 metres from the patient. A visual acuity of 6/18 means the patient, at 6 metres, can only read the line that someone with normal vision could read at 18 metres. Make sure patients use their glasses if they need them for distance vision. A visual acuity of less than 1/60 can be recorded as counting fingers (CF), hand movements (HM), perception of light (PL) or no perception of light (NPL).

• For near vision, use standard test types.

Colour vision

For screening purposes, use Ishihara test plates, testing each eye separately. Ask whether the patient is aware of having a congenital colour vision defect.

Visual fields

• Finger movements or a red pin can be used for testing the peripheral fields, but only a red pin for the central field.

• Sit approximately 1 metre from the patient. Test each eye separately, comparing the patient’s field with your own. For the peripheral field, bring the target object in within the four separate quadrants of the visual field. If a red target is used, ask the patient to identify when he or she can first see the target as red. If individual half fields are full then the target object (in the form of moving fingers) should be presented in both peripheral fields simultaneously.

• Before assessing the central field, map the patient’s blind spot, simply to confirm that the patient is cooperating (in terms of fixation) with the examination. Again ask the patient if he or she can identify the object as red, rather than just seeing it (Fig. 11.3).

Fig. 11.3 Comparison of colour sensitivity between central and peripheral field. In this patient with a central scotoma, the red object appears brown in the central field.

CLINICAL APPLICATION

Optic atrophy

Occurs with any process that damages the ganglion cells or the axons between the retinal nerve fibre layer and the lateral geniculate body. Pallor of the disc follows, often predominating in the temporal aspect.

Papilloedema

Usually bilateral, although sometimes asymmetrical. Successively there is swelling of the nerve fibre layers (best seen with a red-free light), hyperaemia of the disc with loss of its definition and the disappearance of retinal venous pulsation. Eventually there is engorgement of the retinal veins, flame-shaped haemorrhages and cotton wool spots (the last due to retinal infarction). Visual field changes include enlarged blind spots and arcuate defects. Peripheral constriction is a late complication.

Retinal vascular disease

• Central retinal artery occlusion – pallor of the retina with a cherry red spot at the macula. The optic disc is first swollen then pale.

• Central retinal vein occlusion – swelling of the optic disc with dilatation of the retinal veins and haemorrhages.

• Hypertensive retinopathy – initially, variation in calibre of the retinal arteries. Later haemorrhages and cotton wool spots, and finally papilloedema (malignant or accelerated hypertension).

• Diabetic retinopathy – initially produces changes in the microcirculation leading to microaneurysms. Subsequently, haemorrhages, exudates and cotton wool spots appear. Additional features include macular oedema and infarction and new vessel formation (Fig. 11.4).

Fig. 11.4 Diabetic retinopathy. Microaneurysms, haemorrhages, exudates and cotton wool spots.

Optic nerve disease

• The visual defect is monocular and central (central scotoma).

• Visual acuity is reduced along with colour vision.

• There is an afferent pupillary defect.

Chiasmatic lesions

Typically due to a pituitary tumour, craniopharyngioma or meningioma. The resulting field defect is a bitemporal hemianopia, typically asymmetric.

Optic tract and lateral geniculate body lesions

Uncommon. Produce incongruous (i.e. non-matching) homonymous hemianopias.

Optic radiation and occipital cortex lesions

Produce homonymous defects which become increasingly congruous the more posterior the lesion. Occipital lobe lesions produce congruous defects that can be total, quadrantic or scotomatous. An isolated homonymous hemianopia is usually due to vascular disease affecting the occipital lobe.

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Tags: Pocket Guide to Clinical Examination

Apr 20, 2017 | Posted by admin in GENERAL & FAMILY MEDICINE | Comments Off

Absolute central scotoma	Area around fixation in which there is no appreciation of the visual stimulus
Relative central scotoma	Area in which an object is detected but its colour is reduced (desaturated)
Centrocaecal scotoma	A field defect extending from fixation towards the blind spot
Bitemporal hemianopia	Involvement of the temporal halves of both fields
Homonymous hemianopia	Involvement of the temporal half of one field and the nasal half of the other

Fastest Basicmedical Insight Engine

The nervous system

Examination (Fig. 11.1; Review Box p. 229)

Share this:

Like this:

Related

Related posts:

Stay updated, free articles. Join our Telegram channel

Full access? Get Clinical Tree