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Affective Changes : DIAGNOSTIC REASONING: FOCUSED PHYSICAL EXAMINATION

Physical examination can yield little additional data that are of diagnostic value. No physical finding is specific for any psychological disorder. The physical examination should be directed at identifying organicbased conditions that mimic psychological disorders. Perform a comprehensive and thorough physical examination, if the patient has not had one since the onset of symptoms. This chapter presumes that you have performed the physical evaluation for specific presenting symptoms as part of your process to rule out a physiological cause.


Assess Vital Signs

When substance abuse is suspected, vital signs can quickly confirm the presence of an organic condition related to substance intoxication or withdrawal. Abnormal values for body temperature, blood pressure, heart rate, or respiratory rate indicate a need for a thorough evaluation.


Observe General Appearance

Look for signs of depression or substance abuse, such as an unkempt personal appearance, unusual dress, and general state of poor nutrition (skin condition and appearance of hair and nails). Observe the patient’s demeanor and appearance for signs of neglect or a facial expression that might indicate depression. Observe for such behaviors as finger tapping and pacing that indicate anxiety. Methamphetamine users will often have self-induced facial lesions secondary to scratching. Adolescents who are abusing substances sometimes wear clothing or jewelry that displays drug-oriented graffiti.
Observe the infant or child’s engagement. Children
with autism may make few, if any attempts, to contact socially with others, prefer to be alone, and ignore attempts to seek attention, affection, or a connection with their surroundings.


Observe Mental Status

Perform a mental status examination. Assess general behavior. Irritability can occur in patients with anxiety. Note body posture, movement, and facial expressions. Assess for suicidal or delusional thought content, which can occur with substance abuse or psychotic disorders. Determine affect for emotional range (broad or restricted), intensity (blunted, flat, or normal), stability, and congruence with the patient’s stated mood. Evaluate the patient’s cognitive abilities, including attention, concentration, and memory. A number of assessment instruments are available, including the Mini Mental State Examination (MMSE) (see Chapter 9, Figure 9-1 for sample items from the MMSE).

Note Speech and Thought Process

Speech tone, quality, and rate reflect mental status. In depression, the speech can be soft and monotonous with little spontaneity. In mania, the speech can be rapid, pressured, and loud, and the speech content consists of a flight of ideas. Language delay that is not consistent with development should be noted. In some children with autism, language begins to regress instead of increase in skill level.


Examine the Eyes

Substance abusers can have eyes that are injected, jaundiced, puffy, or glassy. Pupils may be dilated or constricted. The patient may have droopy eyelids and a sleepy appearance, or a fixed stare. The patient may have difficulty controlling eye movements.


Examine the Ears, Nose, and Mouth

The ears should be examined. If language delay is suspected, hearing loss or deafness should be ruled out. Substance abusers may have chronic rhinorrhea, frequent nosebleeds, lesions in the nose or around the nostrils, or a perforated nasal septum. The patient may have dry lips, halitosis, or an odor of alcohol, marijuana, or tobacco.


Examine the Skin

Look for skin lesions that reflect depression or anxiety, such as neurogenic scratching, nail biting, and hair pulling. Look for evidence of attempted self-injury or suicide. Adolescents may show evidence of cutting scars, or superficial cuts on areas of the body. Although typically not suicide attempts, cutting serves as a coping mechanism for unrelieved feelings. In substance abusers, the skin may be cold and
clammy, itching and burning, tight, swollen, or puffy. The person may perspire excessively, have discolored fingers, or injection marks along the veins. Tattoos or burn marks, possibly done while under the influence of drugs or alcohol, can disguise injection marks. The patient may have injuries or bruises from falling or fighting.


Assess Balance and Gait

The patient who has a substance abuse problem may have a slow gait or poor balance.