Admissions

Admissions

A. Note:

Most important features are underlined , but these are guidelines only. It can be wasteful and, in emergencies, even dangerous to test everything.

General Exam

• VS : BP, HR, temperature , respirations, orthostatic BP.

• Skin : Petechiae, rash, striae, telangiectasias, caput medusae.

• Head : For trauma exam, see p. 119 .

  • Eye : Papilledema , retinopathy, icterus.

  • Skull : Trauma, craniotomy.

  • Other : Temporal wasting or tenderness, ears, nose, throat, thrush.

• Neck : Stiffness, carotids/bruits , thyroid , jugular distension, nodes.

• Back : Lungs , spine tenderness, pelvic stability.

• Chest : Heart , breasts, nodes.

• Abdomen : Bowel sounds, bruits, palpation, nodes, liver, hernias , scars.

• Genitourinary : Hair, testis size /masses, lesions, pelvic exam.

• Rectal : Guaiac , masses, tenderness, tone.

• Limbs : Pulses , color , edema, splinters/clubbing, calf pain, Homan's sign, range of motion, straight leg raise.

Neurological Exam

• Mental status : For coma exam, see p. 30 . For psychiatric mental status exam (including the Mini-Mental Status Exam), see p. 98

  • Orientation : Self, date, place .

  • Attention : Say months backwards ; spell world backwards.

  • Memory : 3 objects, presidents .

  • Speech : Naming, fluency, comprehension , repetition , read/writing.

    • F test : Number of words beginning with F in 60 sec (>12 if high school education).

    • Passive construction comprehension .

  • Frontal :

    • Perseveration : Go-no go task, copying Luria diagram.

    • Disinhibition : Snout, grasp, imitation behavior.

    • Abulia : Affect, response latency.

  • Parietal :

    • Neglect : Limb recognition, clock draw, bisect line.

    • Calculations : Serial 7's, etc.

    • Praxis : Blowing out a match, tying a shoe.

    • Spatial orientation : Directions, commands across midline.

    • Agnosia : Finger agnosia, anosognosia, alexia without agraphia, color naming.

  • Cognition : Insight, judgment, logic, proverbs, subjunctives.

  • Thought content : Hallucinations, delusions, paranoia .

  • Mood : SIGECAPS criteria, suicidal or homicidal ideation, mania.

• P.12

  
  

• Cranial nerves

  • CN I : Smell.

  • CN II : Pupils, fundi; fields, acuity, blink to threat, red desaturation. Pts with hysterical blindness (see p. 104 ) or cortical blindness have normal pupils, blink to threat.

  • CN III, IV, VI : Horner's, EOMs, saccades, pursuit, optokinetic reflex, cover-uncover test, red glass test, upper lid.

  • CN V : Sensation of forehead/cheek/chin, corneals, jaw.

  • CN VII : Symmetry, brow raise, eye close, nose wrinkle, grimace , cheek puff, anterior taste.

  • CN VIII : Tympani, hearing (see p. 54 ), balance B r ny's test.

  • CN IX-XII : Palate, gag, sternocleidomastoid, trapezius, tongue.

• Motor

  • Strength : Drift, fine finger movements , heel/toe walk, knee bends.

    • Individual muscles : Include hip adductors, pronation/supination, inversion/eversion, abdominal muscles.

    • Subtle signs : Wartenberg's (pull flexed fingers; thumb flexes), stress gait (walk on outside of feet, look for posturing), mirror movements with finger sequencing, testing multiple repeats.

  • Bulk : Atrophy, fasciculations.

  • Tone : Rigidity, spasticity, cogwheeling, dystonic posturing, myotonia. If pt. not cooperative, drop limb to test tone (malingering pts. may not let limb hit face).

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  • Reflexes : Biceps, triceps, brachioradialis, knee, ankle, Babinski.

    • If brisk : Check clonus, spreading, palmomental, jaw jerk, Hoffman's sign (flick nail down, watch for thumb contraction).

    • If frontal damage : Glabellar, grasp, snout, suck.

    • If spinal cord injury : Abdominals, suprapubic, cremasteric, wink, bulbocavernosus.

  • Tests for hysterical weakness : see p. 103 .

• Cerebellar

  • Appendicular : Finger-to-nose, rapid alternating movements, fine finger movements, finger following ( mirror test ), lack of check, toe tapping, heel-to-shin, decreased tone, arm swings after shaking shoulders (nl < 3), pendular reflexes.

  • Axial : Gait, tandem, axial stability, stand on line, walk in circle, march with eyes closed (advancing more than a few feet or rotating more than 30 degrees in 30 sec is abnormal).

  • Voice : Dysarthria, holding a tone, la-la-la, say Methodist-Episcopal, count to 20 fast.

• Sensory

  • Pin : All 4 limbs; trunk for level; nerve distributions, summation.

  • Light touch : Cotton wisp; 2-point discrimination.

  • Proprioception : Joint position, vibration , Romberg, nose touch.

  • Cortical : Dual simultaneous extinction , stereognosis, graphesthesia.

  • P.13

    
    

  • Temperature : Try side of tuning fork or alcohol swab.

  • Anal : If you suspect spinal cord lesion, check anal wink, tone, bulbocavernosus reflex.

  • Tests for hysterical weakness : see p. 103 .

Admission Orders

• Notifications : Speak to family members ; the senior resident; private neurologist; internist, floor or nurse accepting the pt.

• Orders : ADCVAANDISCL .

  • A dmit : Service, admitting physician , resident to page.

  • D iagnosis : Be specific.

  • C ondition : Good, fair, guarded , critical.

  • V ital signs : Specify only if other than per routine.

  • A llergies : List the reaction too, e.g., contrast dye ’ anaphylaxis.

  • A ctivity : Bedrest with head up 30 degrees? Up with assist? Ad lib?

  • N ursing : Pneumo-boots? Guaiac all stools? Etc. Nurses get annoyed that MDs call this category nursing ”it is all nursing.

  • D iet : NPO? Aspiration precautions ? Low salt or cholesterol? DM? Renal? Dysphagia?

  • I ns/Outs : Done automatically in most ICUs; harder to do on general wards. If it is important, consider a bladder catheter. Daily weights may need a special request outside the ICU.

  • S pecial :

    • Oxygen or ventilator settings .

    • Bleed risk? Blood bank sample, guaiac stools, orthostatic BP, large-bore IV.

    • CHF? Strict I/Os, daily weights.

    • Chest pain? Oxygen, cardiac monitor, bedside commode, CPK/isoenzymes/troponins q8h — 3.

    • Mental status change? (see p. 42 ) Restraint — 72 h prn safety, aspiration precautions.

    • Clot risk? Pneumo-boots, SC or low MW heparin (if DVT, full anticoagulation, elevate foot , bedrest), neurovascular checks.

    • Hyper- or hypotension : BP parameters and drugs.

    • Skin care .

  • C onsults : Consider social service, physical therapy, occupational therapy , speech/swallow

  • Tests ( L abs) : bid PTT? Daily PT/INR? qod electrolytes/BUN/Cr?

• Drugs : Consider

  • Rehydration? D5NS at 60 cc/h if concern for brain edema.

  • Sleeping pill? (Avoid if pt confused ). see p. 112 . Zolpidem 5-10 mg, diphenhydramine 25-50 mg, or lorazepam 0.5-1.0 mg.

  • Pain? Acetaminophen 650 mg q4h prn, opiate + constipation rx, etc.

  • GI? E.g., senna tablets, omeprazole 20 mg qd, bisacodyl (Dulcolax) + PR qd prn, milk of magnesia 30 cc q8h prn.

  • P.14

    
    

  • Diabetes? NPH insulin + regular (CZI) sliding scale: for BG <200: 0U; 200-249: 2U; 250-299: 4U; 300-349: 6U; 350-399: 8U; >400: 10U. Alternatively, substitute aspart or lispro at night.

    • Hypertension? E.g., captopril 25 mg PO, or metoprolol 50 mg PO bid prn SBP >180. For IV drugs, see p. 172 .

    • Hypotension? IV fluids; consider midodrine 10 mg PO tid or IV drugs (see p. 172 ).

  • Chest pain? Avoid hypotension in stroke or carotid dz.

    • SL nitroglycerine : 0.3 mg q5min prn — 3 while SBP >120.

    • NTP SS : q4h for SBP <120: wipe, 120-134: 0.5 in.; 135-149: 1 in.; 150-164: 1.5 in.; >165: 2 in.

• Admission note : Age, handedness , chief complaint, history of present illness , past medical history, allergies, medicines, family and social history (always include education), review of systems, physical exam, labs, assessment, plan.

  • Assessment by issues : Neuro, cardiovascular (pump, rate, rhythm, valves , etc.), pulmonary, renal, fluids/electrolytes/nutrition, infectious dz, GI, GU, hematologic, endocrine, dermatologic, oncologic, orthopedic, psychiatric, rheumatologic, code status, discharge plan.

  • Etiologies : Traumatic, vascular , high ICP, toxic, metabolic , psychiatric, infectious, inflammatory, neoplastic, epileptic, degenerative.