これはこれからは"Nutrition-Focused Physical Assessment"はRDの役割の一つになっていくかもしれません。皮膚、頭、首、場合によってはお腹などをアセスメントします。
特に気になっているのが脳神経のアセスメント（cranial nerves）。食事に関するのは、CN VII(第VII脳神経) (muscles and facial expression), IX (gag reflex, swallow), X (tongue range of motions, XII (cough reflex, drooling, facial weakness and ability to perform a wet and dry swallow. TMJ assessment。
◎クラスディスカッションより
•Neurological: Cognition – observe for ability to follow simple directions; ask the patient questions about his name, date, and location. Cranial nerves: assess the functions of the cranial nerves associated with swallowing and mastication. Ascertain sense of smell, strength of the temporal and masseter muscles, facial movements, gag reflex and strength of the trapezius and sternomastoid muscles.
oTrigeminal (V) – ask the patient to clench his teeth while palpating the temporal and masseter muscles, note the strength of muscle contraction; ask the patient to move his jaw from side to side. In masseter and lateral pterygoid muscle weakness there will be difficulty in clenching the jaw or moving it from side to side respectively.
oGlossopharyngeal (IX) and vagus (X) – abnormalities in these nerves can lead to swallowing difficulties from pharyngeal or palatal weakness. Ask the patient to say “ah” and listen to his voice for hoarseness (may indicate voice cord paralysis) or a nasal quality to the voice (may indicate paralysis of the palate). Also, watch the soft palate (failure to rise may indicate a bilateral lesion in the vagus nerve or if only one side fails to rise, a unilateral paralysis). Testing the gag reflex is important as absence of the reflex can point to a lesion of the glossopharyngeal and vagus nerves.
oHypoglossal nerve (XII) – inspect the patient’s tongue looking for asymmetry, atrophy or deviation form the midline as the tongue is protruded. Ask patient to move the tongue from side to side to assess for symmetry of movement. If asymmetry, a cortical lesion may be present.
What factors may be contributing to his symptoms?
1. The patient may be experiencing difficulty swallowing because of weakness of pharynx or palate due to lesions in the glossopharyngial and vagus nerves. If the gag reflex was absent or the palate failed to rise, we would suspect this to be the problem. However, since this patient is only 49 years old, it would be unlikely.
2. The patient may be experiencing symptoms from a stroke (also, unlikely given his age, but not impossible), which would be affecting the trigeminal nerve and causing facial sensory loss. If we perform a sensory test and find that the patient is incapable of distinguishing between sharp and dull objects, we could suspect this to be the problem.
3. There may be weakness of the masseter and pterygoid muscles again due to problems with the trigeminal nerve. This could lead to problems of mastication and swallowing because food has not been chewed properly.
4. The patient may be experiencing gastroesophageal reflux disease (GERD), which occurs in 30% to 40% of adults. Some patients with GERD experience pharyngeal symptoms (hoarseness, sore throat). Some patients may develop peptic strictures which progress to dysphagia for sold foods. As our text states “some patients may have alarm symptoms such as difficulty swallowing, pain with swallowing, and weight loss among others.” These symptoms warrant endoscopy to detect esophagitis, peptic strictures or Barrett’s esophagus. If GERD is present, overweight could be a contributing factor.
References
•Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking. Tenth Edition. Lippincott Williams & Wilkins. 2009.
•A simulated approach to examination of the head, neck, and oral cavity CD-ROM. 2004-2008. UMDNJ-SHRP.
•The Merck Manual for Healthcare Professionals. Gastrointestinal Disorders: Esophageal and Swallowing Disorders: Dysphagia. Available at: http://www.merck.com/mmpe/sec02/ch012/ch012b.html?qt=difficult%20swallowing&alt=sh#sec02-ch012-ch012b-555b. Accessed on February 15, 2009.
あと、口の中のアセスメント（Intra- oral exam involving inspection of lips, oral mucosa, gums, teeth, roof of the mouth, tongue, floor of the mouth, pharynx）も気になります。実習楽しみです。
足のアセスメント
足にむくみ、色の変化（濃い紫）、乾燥、傷などが見られる場合は、高血圧、venous insufficiency、venous hypertension,congestive heart failure、Peripheral vascular disease、肝臓病、糖尿病などの可能性あり。肥満の人ではリスク↑。 やっぱりそうなると食事面では、減塩食、体重管理、血糖値管理などが重要でしょうか。もちろん言うのは簡単ですが、こういった食事を実行するのは容易ではないでしょう…。
http://www.visualdxhealth.com/adult/diabeticDermopathy.htm
ところで話は変わりますが、クラスメートの話によると、職場でNCP（Nutrition Care Process）を使っている病院も結構あるようです。今のところ、診断の部分だけのようですが、これからインターベンションやモニタリングも入れていくと言っていました。
特に気になっているのが脳神経のアセスメント（cranial nerves）。食事に関するのは、CN VII(第VII脳神経) (muscles and facial expression), IX (gag reflex, swallow), X (tongue range of motions, XII (cough reflex, drooling, facial weakness and ability to perform a wet and dry swallow. TMJ assessment。
◎クラスディスカッションより
•Neurological: Cognition – observe for ability to follow simple directions; ask the patient questions about his name, date, and location. Cranial nerves: assess the functions of the cranial nerves associated with swallowing and mastication. Ascertain sense of smell, strength of the temporal and masseter muscles, facial movements, gag reflex and strength of the trapezius and sternomastoid muscles.
oTrigeminal (V) – ask the patient to clench his teeth while palpating the temporal and masseter muscles, note the strength of muscle contraction; ask the patient to move his jaw from side to side. In masseter and lateral pterygoid muscle weakness there will be difficulty in clenching the jaw or moving it from side to side respectively.
oGlossopharyngeal (IX) and vagus (X) – abnormalities in these nerves can lead to swallowing difficulties from pharyngeal or palatal weakness. Ask the patient to say “ah” and listen to his voice for hoarseness (may indicate voice cord paralysis) or a nasal quality to the voice (may indicate paralysis of the palate). Also, watch the soft palate (failure to rise may indicate a bilateral lesion in the vagus nerve or if only one side fails to rise, a unilateral paralysis). Testing the gag reflex is important as absence of the reflex can point to a lesion of the glossopharyngeal and vagus nerves.
oHypoglossal nerve (XII) – inspect the patient’s tongue looking for asymmetry, atrophy or deviation form the midline as the tongue is protruded. Ask patient to move the tongue from side to side to assess for symmetry of movement. If asymmetry, a cortical lesion may be present.
What factors may be contributing to his symptoms?
1. The patient may be experiencing difficulty swallowing because of weakness of pharynx or palate due to lesions in the glossopharyngial and vagus nerves. If the gag reflex was absent or the palate failed to rise, we would suspect this to be the problem. However, since this patient is only 49 years old, it would be unlikely.
2. The patient may be experiencing symptoms from a stroke (also, unlikely given his age, but not impossible), which would be affecting the trigeminal nerve and causing facial sensory loss. If we perform a sensory test and find that the patient is incapable of distinguishing between sharp and dull objects, we could suspect this to be the problem.
3. There may be weakness of the masseter and pterygoid muscles again due to problems with the trigeminal nerve. This could lead to problems of mastication and swallowing because food has not been chewed properly.
4. The patient may be experiencing gastroesophageal reflux disease (GERD), which occurs in 30% to 40% of adults. Some patients with GERD experience pharyngeal symptoms (hoarseness, sore throat). Some patients may develop peptic strictures which progress to dysphagia for sold foods. As our text states “some patients may have alarm symptoms such as difficulty swallowing, pain with swallowing, and weight loss among others.” These symptoms warrant endoscopy to detect esophagitis, peptic strictures or Barrett’s esophagus. If GERD is present, overweight could be a contributing factor.
References
•Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking. Tenth Edition. Lippincott Williams & Wilkins. 2009.
•A simulated approach to examination of the head, neck, and oral cavity CD-ROM. 2004-2008. UMDNJ-SHRP.
•The Merck Manual for Healthcare Professionals. Gastrointestinal Disorders: Esophageal and Swallowing Disorders: Dysphagia. Available at: http://www.merck.com/mmpe/sec02/ch012/ch012b.html?qt=difficult%20swallowing&alt=sh#sec02-ch012-ch012b-555b. Accessed on February 15, 2009.
あと、口の中のアセスメント（Intra- oral exam involving inspection of lips, oral mucosa, gums, teeth, roof of the mouth, tongue, floor of the mouth, pharynx）も気になります。実習楽しみです。
足のアセスメント
足にむくみ、色の変化（濃い紫）、乾燥、傷などが見られる場合は、高血圧、venous insufficiency、venous hypertension,congestive heart failure、Peripheral vascular disease、肝臓病、糖尿病などの可能性あり。肥満の人ではリスク↑。 やっぱりそうなると食事面では、減塩食、体重管理、血糖値管理などが重要でしょうか。もちろん言うのは簡単ですが、こういった食事を実行するのは容易ではないでしょう…。
http://www.visualdxhealth.com/adult/diabeticDermopathy.htm
ところで話は変わりますが、クラスメートの話によると、職場でNCP（Nutrition Care Process）を使っている病院も結構あるようです。今のところ、診断の部分だけのようですが、これからインターベンションやモニタリングも入れていくと言っていました。